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i^ JM 

Columbia ©nitiem'tp 

College of ^ijpgiciang axih burgeons 

Digitized by the Internet Archive 

in 2010 with funding from 

Open Knowledge Commons 








Dr. Med. (Berlin) 












Copyright, 1914, by 



Printed in the United States of America 








During many years I have been impressed with the necessity 
of a thorough understanding of pain phenomena in the making 
of a diagnosis. Pain is universal, and is present in practically 
every disease, and in most diseases it is the one symptom which first 
attracts the patient's attention and causes him to become aware 
of some change in his physical well-being. The patient then 
comes to the physician, who, unless he is well versed in the inter- 
pretation of pain phenomena, may be at a loss to interpret the 
symptoms which are presented to him. To do so he needs to 
know not only the various factors to which a certain pain may 
be due, but also the reasons should be produced and the 
different diseases giving rise to pain of similar character and loca- 
tion. To understand thoroughly these latter factors the physician 
must needs be versed in all the essentials and components of which 
a pain consists, its causes, character, varieties, its localizations 
and the changes induced by its presence. 

It was with the idea of supplying easily accessible informa- 
tion along these lines that I undertook the composition of this 
book. To those, who, like myself, have felt the need of such a 
book, I offer it with the hope that it may be of some help to them. 
To make it as complete as possible has been my endeavor, and to 
do so I have thoroughly searched the literature and culled from it 
all that I tliought might be of use. I believe credit has been 
given in all cases to the authors of my references, but if, through 



an unintentional oversight, this has been neglected, I beg that my 
attention may be called to it so that it can be remedied. 

It is with the gTeatest pleasure that I express my thanks to 
Dr. T. L. Disque, Dr. Wm. H. Glynn, Dr. E. C. Stuart, who so 
kindly granted me the use of an abundant material from his 
surgical service ; to Goldsmith of Vienna, who reviewed " the 
anatomical section of my work; to Dr. Frankel of the same city, 
who reviewed my gynecology section; to Dr. Smith Ely Jelliffe, 
who has reviewed the entire work; to Mr. Sander of Vienna; and 
Dr. Erenzel and Dr. Powers of Berlin ; to Miss Esther Hrubesky 
of Berlin, who has aided me in revising my proofs and illustrations. 

E. J. Behan. 
212 South St. Claik Stkeet 





Sensation in Lower Animals ....... 1 

Reaction of Animals to Pain ....... 3 

General Consideration op Sensation ..... 4 

Properties of Sensation ........ 6 

Centers for Sensory Perception and the Sense Organs . . 7 
Sense Perceptive Organs . . . . . . . .11 

Stimuli . . . . . . . . . . . 12 

Interpretation of Sensation ....,,, 12 


Definition ....... 

Metaphysical Consideration of Pain 

Memory Centers for Pain .... 

Causative Factors in the Production of Pain . 
Apparatus for Receiving and Conducting Pain 
Pain and Mental States ..... 

Relation of Pain to Other Sensations 
Conveying Channels for Sensations 


Distribution of the Sensation of Pain .... 




Analgesia . . . . . . . . . . .61 

Anesthesia .......... 63 

Hyperalgesia .......... 67 








Subjective Pains 

Emotional pains 



Habit pains . 

Monomania pains 

Occupation neuroses 
Objective Pains 

Central objective pain 

Peripheral objective pain 


Peripheral Objective Pains 
Propagation of pains 
Character of the pain 
Persistency of paia 
Time of the pain . 
Sensitiveness to pain 
Individual susceptibility 


Factors upon Which Intensity Depends . 

The stimulus . , . . 

Sensitiveness of the patient . 

Irritability of the nerves 

Extent and number of nerve fibers involved 
Factors Modifying Pain Production . 

Psychical factors ..... 

Physical factors ..... 
Estimation of the Intensity of Pain 

Blood-pressure elevation 

Motor reflexes ..... 

Complaints of patient compared with his suscei^tibility 

Vasomotor signs ....... 




Dilatation of the pupil 

. 125 

Amount of morphine necessary to overcome pain 

. 125 

Appearance of patient . 


. 125 

Patient's description 

. 128 

Mechanical factors 


. 129 

Conditions Associated with 


ERE Pain 

. 132 

Eespiratory system 

. 134 

Circulation . 


. 134 

Loss of equilibrium 


. 134 

Trophic changes . 

. 134 

Preprotective functions . 


. 135 

Elevation of temperature 

. 135 

Method of Recording Pain 

. 135 


Affections of the Nerve Terminals and Nerve Trunks 

Etiology ...... 

Symptoms ...... 

Duration of neuralgia .... 

Diagnosis of neuralgia .... 

Tyi^es of neuralgia accoi'ding to localization 
Central Nervous System .... 

Anatomy ... 

Origin of headache .... 

Headache in disease of the brain and meninges 

Diagnosis of headache in diseases of the brain and meninges 

Differential diagnosis ....... 



Cord Conditions Which Cause Pain . 
Meningeal apoplexy 
Hematomj^elia .... 
Caries of the vertebral canal 
Tumors of the spinal cord and vertebn 
Acute spinal meningitis 
Pachymeningitis spinalis hypertroj^hica 


Poliomyelitis of children 

Syphilis of the meninges and of the cord 

Multiple sclerosis ..... 




Tabes dorsalis 

Traumatic neuroses 
General summary . 



MuscrLAR Tissues 
YoLuxTARY Muscles . 

Acute polymyositis 
Myositis hemon'hagica 
Myositis fibrosa 
Myositis ossificans 


Colics , 
Fatty Tissues . 

Adiposis dolorosa . 



General Consideratioxs 
Types of Paix . 

Continuous pains . 

Intermittent pain . 

Diurnal variation of the pains 
Character of Boxe Paix 
Localized Boxe Paix 

Periosteal lesions 

Traumatism • 



New gTOwths 

Septic involvement 
Gexeralized Boxe Paix 


Diseases of the hemopoietic system 

Sarcoma and carcinoma 

Myeloma, Ij'mphadenoma ossium, and chloroma 


Osteitis deformans 

Leontiasis ossea 

Spurs . 
Differential Diagnosis of Bone Pain 
Joint Pains — Arthralgia 


Radiation of joint pains 

Intensity of the pain 


Diagnosis of inflammatory joint pains 

Hip joint ..... 

Tension pain of intra-articular hip-joint abscess 




Pain Caused by Changes in the Blood 

Pains from increase in blood supply 

Pains from diminution in blood supply 
Arterial Diseases Causing Pain 

Inflammation ...... 

Increase of blood pressure . . . 

Intermittent claudication .... 

Erythromelalgia ...... 

Embolism and thrombosis of the mesenteric arteries 

Aneurysm . ' . 
Diseases of the Veins Causing Pain 

Inflammation of the veins .... 

Thrombosis ....... 

Varicose veins . . . 



The Glands 

The Mammary Gland 

The Adrenals . 

The Mesenteric Glands 

The Thymus and Thyroid 



The Head . . . . . 

Sense of pressure in head 

Head pain ...... 

Diagnosis of headache .... 




Pain in the Back . 296 

Lungs 300 

Heart and aorta . . . . . . . . . 301 

Stomach 301 

Intestines 302 

Liver and gall-bladder ........ 302 

Kidney 302 

Pancreas, spleen, etc. ........ 303 

Anemia and chlorosis ........ 304 

Pain in the Limbs ......... SOI- 

Pain in the Abdomen ........ 307 

Chest Pain 310 

Clavicular Pains 310 

Neck Pains 312 

Summary 312 


Etiology 317 

Localization of Pains 318 

The eyelids 318 

Surroundings of the eye ....... 322 

Conjunctiva and cornea ....... 322 

The iris and ciliary body . . ... . . . 325 

Sclerotic coat ......... 327 

Choroid, retina and optic nerve ...... 328 

Glaucoma . . . . . . . . . . 329 

Panophthalmitis ......... 330 

Asthenopic disorders ........ 330 



External Ear • . 332 

External Auditory Canal . . . . . . . . 333 

Tympanum .......... 335 

Middle-ear Disease , , • 335 

Middle-ear Catarrh 339 

Otosclerosis .......... 339 

Labyrinth .......... 339 

Referred Pain .......... 340 




The Sensory Nerves of the Nose ...... 341 

Diseases Which Produce Pain and Their Manner of Production 342 

Nasal Stenosis .......... 342 

ElIPYEMA ........... 343 

Headache from Disease of the Sphenopalatine Ganglion . 345 

Tumors 347 

Diagnosis 348 


Pain in Diseases of the Pharynx . . . . . . 351 

Pain in acute diseases ........ 351 

Pain in chronic diseases ....... 354 

Pain in the Larynx ......... 356 

Pain in acute affections . ... . . . . 357 

Chronic processes ......... 358 



Classification 360 

Subjective Pain 360 

Objective Abdominal Pain . . . ■ . . . . 360 

Inflammations of the Peritoneum . . . . . . 364 

Tumors of the Peritoneum ....... 367 

Nature of Pain from Adhesions ...... 367 

Nature of Pain in Hernia ....... 371 


History 377 

Location of Pain ......... 383 

Transference of Pain ........ 384 



Nature of Various Abdominal Pains 
Examination for Pain .... 

Localization of pain .... 

Localization of organ producing pain 

Lesions causing epigastric pain 

Pain due to functional processes 

Pain due to intestinal diseases 

Abdominal tenderness .... 
Posture in Abdominal Diagnosis 
Forms of Abdominal Pain 

Functional pains ..... 

Care in diagnosis ..... 
Conditions Associated with Abdominal Pain 

Spasm and rigidity of muscles 

Visceromuseular reflex ... 

Toxemia . . . . . 

Indicanuria ...... 

Polyuria ...... 

Relationship of hysterical to abdominal pain 
Abdominal incisions .... 

Post-operative abdominal pain 

Pain referred to extra-abdominal regions 

Absence of pain . . . . . 




Lips .... 




Salivary Glands 

Pharynx and Tonsils 



Areas of Referred Pain Caused by Stomach Disorders 

Pain in Gastric Areas 

Character of gastric pain ..... 
Time and manner of its appearance 



Relationship to ingestion of food . 

Duration of pain ..... 

Previous attacks ..... 

Associated symptoms . . • . 

Pain reflected or referred to gastric areas 
Lesions of Stomach Causing Pain . 

Displacement of the stomach (gastroptosis) 

Gastralgia or gastromyalgia . 

Hyperehlorhydria .... 

Pyloric or cardiospasm 

Acute dilatation of the stomach . 

Acute gastritis ..... 

Chronic gastritis ..... 

Gastric erosions . . . . 

Gastric ulcer ..... 

New growths of the stomach 

Perigastric adhesions .... 
Referred Pains Confused with Those of Gastric Origin 






General Considerations . 

. 463 

Etiology of pain . . ■ . 

. 463 

Location of pain ..... 

. 469 

Type of pain .... 

. 470 

Manner of onset .... 

. 471 

Relation of the position of the patient to the pain 

. 472 

Relation of the ingestion of food to the pain 

. 472 

Duration of pain ...... 

. 473 

Result and histoiy of the pain 

. 473 

Tenderness ..... 

. 474 

Symptoms associated with the pain 

. 474 

Lesions of the Intestines Causing Pain 

. 476 

Enteralgia ..... 

. 476 

Pain due to functional disturbances 

. 477 

Type of pain in colic . 

. 483 

Inflammation of the bowel 

. 484 

Ulcers of the intestine . 

. 487 

Distention of the bowel 

. 491 


. 491 

Obstruction of the intestine . 

. 492 

The rectum 

. 505 

The anus 

. 509 





Varieties of Appendiceal Pain 516 

Tenderness in Appendicitis 529 

Symptoms Associated with Pain Production in Appendicitis . 535 

Differential Diagnosis 537 


General Considerations 540 

Nerve supply . . . . . . . . . 540 

Pain of the Liver 545 

Character of the pain ........ .545 

Relation to the ingestion of food and drink . . . ' . 545 

Relation to the movement of the body . . . •. . 547 

Position of the body ........ 547 

Relationship to other diseases and processes .... 548 

Time of appearance of pain ...... 549 

Neuralgia .......... 550 

Pains due to the disturbance of the liver substance proper . 550 

Gall Bladder .......... 562 

General etiology ......... 562 

Diagnosis .......... 563 

Diseases causing pain ........ 568 

Gall-duct Pain . . . . . . . . . . 572 

Etiology . .572 

Location of pain ......... 573 

Character of pain ......... 573 

Associated symptoms ........ 576 

Differential diagnosis ........ 577 


General Considerations • . 580 

Nerve supply . . . . . . . . . 581 

Structure of the pancreas ....... 582 

Peritoneal covering ........ 583 

Relationship to other parts ....... 584 

Character of pain ......... 585 

Location of pain ......... 585 




Tenderness . 586 

Position of the patient . 


. 587 

Diseases of the Pancreas Causing Pain 


. 587 

Pancreatitis ..... 


. 587 


. 589 

Cystic disease of the pancreas 


. 591 

Cancer of the pancreas 

• « 

. 591 


General Considerations 
Nerve supply 
Position of patient 
Tenderness . 
Factors influencing pain 
Disorders of the Spleen Producing Pain 
Displaced or movable spleen 
Congestion . 
Abscess of the spleen 

Rupture of the spleen 
Tumors of the spleen 
Cysts of the spleen 



General Considerations 

Nerve supply 

Etiology of kidney pain 

Character of renal pain 

Localization of kidney pain 

Tenderness . 

Factors influencing production of pain . 

Absence of pain in kidney lesions 

Symptoms associated with pairi phenomena 

Pain in diagnosis of kidney lesions 
Differential Diagnosis of Kidney Diseases Causing 

Movable kidney 

Renal infarction . 

Hematuric nephralgia 

Inflammation of the kidney 





Perinephritis . . . • • • • • • 637 

Rupture of the kidney ........ 641 

Tuberculosis of the kidney . . . . . . . 642 

New growths ......... 644 

Pyelitis 647 

Hydronephrosis ......... 653 

Renal calculus . . . . . • . ... 655 


The Ureter 670 

The Bladder 672 

General considerations ........ 672 

Bladder affections causing pain . . . . . . 683 

The Urethra 695 

Urethral caruncles . . . . . . . . 695 

Calculus . . .696 

Rupture of the urethra . . . . . . . 696 

Transferred pain in urethral disease ..... 696 

Pain on urinating ........ 696 



The Testicles 698 

Epididymis^ Vas Deferens^ and Seminal Vesicles . . . 699 

The Prostate 700 

Congestion and inflammation ...... 700 

Lesions . . . . . . . . . . 701 

Hypertrophy ......... 701 

Tumors of the prostate ....... 702 

Tuberculosis . 702 

Associated symptoms ........ 702 

The Penis 703 

Urethritis .703 

Inflammation of the prepuce . . . , . . 703 

Inflammation of Cowper's glands ...... 703 



General Considerations 705 

Anatomy .......... 705 

Nerve supply ......... 705 





Diagnosis of pelvic and hysterical pain .... 709 

Varieties of pain ...... 

. 712 

Character of uterine pains 

. 716 

Diagnosis of the pelvic diseases 

. 722 

Uterine Pain . . . - , 

. 724 

Character of uterine pains . 

. 724 

Neuralgia .... 

. 726 

Displacement of the uterus . 

. 726 

Functional disorders of the uterus 

. 728 

Inflammation of the uterus . 

. 740 

New growths of the uterus . 

. 743 

Fallopian Tubes 

. 744 

Tubal conditions causing pain 

. 744 

Extrauterine pregnancy 

. 746 


. 747 

Local point of pain 

. 748 

Causes of pain .... 


Neuralgia of the ovary 

. 749 

Displacement of the ovary . 

. 749 

Hernia of the ovary . 

. 749 

Hyperemia of the ovary 

. 749 

Abscess of the ovary . 

. 751 

Tuberculosis .... 

. 752 

Enlarged uterus .... 

. 752 

Relationship of ovaries and parotids 

. 752 

Cysts of the ovary 

. 753 

The Vagina . . . . 

. 755 

Nerve supply 

. 755 

Affections causing pain . 

. 755 

Sexual connection . 

. 756 


The Thoracic Walls 

The skin 

Muscles, fascia and nerves 

Nerve and muscle pain . 

Bone pain 

Pleural pain 
Referred and Reflected Pains of the Thoracic Walls 

Localization of pain on the chest wall . 
Pains v^^ithin the Thorax ..... 

The pleura ........ 





General Considerations 773 

Nei-ve supply of the heart- ....... 774 

Diagnosis by means of location of referred pain . . . 774 

Intracardiac lesions as causes of pain ..... 782 

Angina Pectoris . 783 

Etiology 783 

Character of the pain in angina pectoris .... 784 

Location of the pain ........ 785' 

Local tenderness ......... 787 

Associated sjTnptoms ........ 787 

Disease of the Pericardium ....... 788 


The Lungs .... 

General considerations . 
Diseases of Thoracic Organs Causing 

Acute bronchitis . 

Pneumonia .... 

The Mediastinum 








1. — Right cerebral hemisphere seen from the outside . . 9 
2. — Inner surface of right cerebral hemisphere .... 9 
3. — Schematic illustration showing how the various sensations are 
transmitted from the periphery to the brain cortex and 
from thence to the two brain centers .... 23 
4. — Diagram showing how changes in the cell metabolism may- 
produce changes in the irritability of the cell and a de- 
parture in its reaction to external stimuli, either making 
it more or less sensitive to peripheral irritation . . 27 

5. — Areas of epicritic and protopathic sensibility ... 38 
6. — Effect of injury to the pain-conduction paths in the cord . 39 
7. — Unilateral complete lesion on one side of the cord producing a 
narrow band of anesthesia on the same side at the level of 
the lesion and a broader zone of anesthesia on the opposite 
side slightly below the level of the lesion ... 39 
8. — Cross section of the spinal cord ..... 40 
9. — Diagram showing intraspinal course of sensory fibers . . 43 

10. — Course of the different sensory (peripheral) fibers, according 

to Head 44 

11. — Cutaneous sensory nerve supply to the lower limbs. (After 

Toldt.) 49 

12. — Cutaneous distribution of peripheral nerves. (After Fowler.) 50 
13 and 14. — Cutaneous nerve supply, showing the distribution areas 

of the different plexuses. (Toldt.) .... 51 

15. — Distribution areas of the nerves (from lumbar plexus) distrib- 
uted to the anterior surface of the thigh and abdomen . 52 
16. — Distribution of the nerves derived from the sacral plexus . 53 
17. — Dorsal nerves ......... 54 

18. — Cord zones according to Koeher ...... 55 

19. — Cutaneous areas related to spinal cord segments and cutaneous 

distribution of nerves . . . ... . .56 

20. — Areas of anesthesia and paralysis corresponding to affected 

vertebrae ......... 57 

21. — Distribution of the lumbar segments according to Thorburn 57 
22. — Distribution of lumbar and sacral segments as outlined by 

Starr 57 



23. — Relationship of the segments of the spinal cord and their 

nerve roots to the bodies and spines of the vertebrae . 58 
24. — Cord zones and areas of maximum tenderness according to 

Head • • .59 

25. — Cord zones and areas of maximum tenderness according to 

Head 59 

26. — Cord zones and areas of maximum tenderness according to 

Head 59 

27. — Areas of anesthesia on leg due to depressed fracture of skull 64 

28. — Method of eliciting hyperalgesia ...... 67 

29. — Areas of analgesia in hysteria ...... 78 

30. — Method of pain production in inflammation . . . 85_ 

31. — Varieties of pain: Origin and transmission ... 89 
32. — Scheme showing how the different varieties of pain may arise 

and how the different musculo-sensory reflexes may occur 90 

33. — Varieties of pain: Origin and transmission ... 91 
34-36. — Case illustrating upward reference of pain . . .99 
37. — Hand pressing on the abdomen, very characteristic of colic, 

i.e., of the uterus or intestine ..... 126 
38. — ^Position assumed in uterine colic, intestinal colic, and distended 

urinary bladder ........ 127 

39. — Lacing shoe position ........ 128 

40. — Pain on hyperextension of the body ..... 129 

41. — Pain on going upstairs ....... 129 

42. — Marking code of Dr. Harris . . . . . .136 

43. — Figures showing the application of the marking code of Dr. 

Harris ......... 137 

44. — Areas of neuralgic pain ....... 148 

45. — Brachial plexus ......... 151 

46. — Areas of distribution of nerves derived from the brachial 

plexus . . . . . . . . . 152 

47. — Areas of distribution of nerves derived from the brachial 

plexus ......... 152 

48. — Distribution areas of the cutaneous nerves of the upper limbs 154 
49. — Areas of distribution of the different cords of the brachial 

plexus ......... 155 

50. — Distribution of sensory disturbances in a lesion of the fifth 

cervical nerve ........ 156 

51. — Area of distribution of pain in lesions of the sixth and seventh 

cervical nerve . . . . . . . . 156 

52. — Distribution of sensory disturbances in lesions of the cervical 

plexus ......... 157 

53. — Area of anesthesia in a lesion of the first dorsal nei-ve . , 157 

54. — Method of eliciting pain in brachial neuralgia . . . 158 



55. — Method of eliciting the. points of tenderness in intercostal 

neuralgia ......... 164 

56. — Cutaneous distribution areas of small and greater sciatic . 167 

57. — Method of eliciting pain in sciatica ..... 168 

58. — Distribution of the plantar nerves ..... 169 

59. — Pain in skin over back and shoulder due to disease of shoulder 

joint 235 

60. — Obturator and accessory obturator ..... 240 

61. — Pain areas in the head ....... 263 

62. — Pain areas in the head ....... 264 

63. — Figure illustrating the places where induration takes place . 266 

64. — Locations of the principal headaches ..... 278 

65. — Locations of the principal headaches ..... 279 

66. — Occipital headache ........ 280 

67. — Fronto-temporal headache . . . . . . . 280 

68. — Temporal headache . . . . . . . . 281 

69. Frontal view of Head's zones ...... 291 

70. — Lateral view of Head's zones . . . . . . 292 

71. — Lateral view of Head's zones ...... 293 

72. — Posterior view of Head's zones . . . . . . 294 

73. — Figure showing the modifications of pain in the lumbar region 

by change of position ....... 298 

74. — Pain areas in trunk and lower extremities .... 308 

75. — Pain areas in breast and abdomen . . . . . 309 

76. — Pain areas in neck, chest, clavicular region and abdomen . 311 

77. — Pain areas in the back . . . . . ... 313 

78. — Pain areas in spinal column ...... 314 

79. — ^Pain areas in back . . . . . . . . 315 

80. — Posture assumed in earache . . . . . . 335 

81. — Scheme of innervation of abdominal viscera . . . 379 
82. — Figure showing the anterior distribution of the ninth, tenth, 

eleventh and twelfth dorsal nerves . . . . 385 

83. — Anterior view of abdominal zones with corresponding organs 395 

84. — Posterior view of abdominal zones ... , . . 396 
85. — Areas of local tenderness, when the inflammation of the appen- 
dix, gall bladder, and Fallopian tube and ovary has spread 

to the peritoneum and has produced a localized peritonitis 404 

86. — Posture of abdominal protection present in pei'itonitis . . 406 

87, — Position in abdominal colic, assumed on lying . . . 407 

88. — Position in abdominal colic, assumed on sitting . . . 407 

89. — Areas of referred pain as given by Head .... 427 

90. — Nervous supply of the stomach ...... 428 

91. — Location of the pain symptoms in a case of hyperehlorhydria 435 

92.— Pain radiation 436 

93. — Location of pain in acute gastritis ..... 441 



94. — Location of pain in gastric ulcer ..... 443 

95. — Sites of tenderness in gastric ulcer, ulcer of pylorus and ulcer 

of duodenum ........ 446 

96. — Sites of tenderness in gastric ulcer, posterior view . . 446 
97. — ^Hyperalgesic zones in cancer at cardiac end of stomach . 456 
98. — Point of tenderness and the area of pain in a case of peri- 
gastric adhesions ........ 460 

99. — ^Anterior \dew of areas of referred pain in intestinal diseases 466 

100. — Posterior view of areas of referred pain in intestinal diseases 466 
101. — Points to which pain is referred in lesions of different parts of 

intestinal tract ........ 467 

102. — Pain areas in colonic colic ....... 481 

103. — Pain areas in intussusception ...... 498 . 

104 and 105. — Areas of pain in diseases of colon .... 500 

106. — Irritation at external sphincter referred to skin over coccyx . 510 
107. — Cutaneous and muscular distribution of eleventh and twelfth 

thoracic nerves ........ 515 

108. — Areas supplied by the posterior branches of the eleventh and 

twelfth thoracic nerves ...... 520 

109. — Areas of pain referred from the appendix .... 521 

110 and 111. — Areas of cutaneous hyperalgesia in appendicitis cor- 
responding to the eleventh dorsal area of Head . . 522 
112. — Reflected pain in appendicitis. Triangle of cutaneous tender- 
ness .......... 523 

113. — Reflected pain in appendicitis. Small area of cutaneous ten- 
derness occasionally present ...... 523 

114. — Reflected pain in appendicitis. Rounded patch of cutaneous 

tenderness in lumbar region . . . . . . 523 

115. — Location and radiation of sympathetic reflected pain in appen- 
dicitis 524 

116. — Location and radiation of sympathetic reflected pain . . 524 

117. — Areas of hyperalgesia in the eleventh dorsal visceral segment 

due to appendicitis of the catarrhal type . . . 525 
118. — Areas of increased sensitiveness to pain and to touch in appen- 
dicitis . . . . . . . . . 526 

119-121. — Pain in the left side in appendicitis .... 528 

122. — Areas of referred pain in liver diseases : Anterior view . 541 
123. — Areas of referred pain in liver diseases : Posterior view . 541 
124. — Areas of referred pain in liver diseases : Lateral view . . 542 
125. — Relationship of nerve supply of liver to cerebrospinal and sym- 
pathetic systems . . . . . . . . 543 

126. — Area of greatest tenderness in diseases of the gall bladder 

and appendix ........ 564 

127. — Method of eliciting gall-bladder tenderness .... 565 

128. — Radiation of gall-bladder pain as given by Schmidt . . 566 



129. — Nerve supply to pancreas .... ... 581 

130. — Distribution areas for pain due to pancreatic lesions . -. 582 

131. — Relation of pancreas to posterior abdominal wall . . 583 

132. — Pain areas in disease of pancreas ..... 590 

133. — Points of pain and tenderness in diseases of the spleen . 595 

134. — Points of pain and tenderness in diseases of the spleen . 595 

135. — Method of palpating for splenic tenderness . . . 596 

136. — Location of the kidney ....... 597 

137. — Areas of referred and reflected pains in diseases of the urinary 

apparatus ......... 609^ 

138. — Nerves involved in referred pain from kidneys . . . 611 
139. — Distribution of cord zones (according to Head) and of 

nerves ......... 613 

140. — Areas of reflected hyperalgesia, in tenth, eleventh and twelfth 

dorsal, and first lumbar visceral segments (according to 

Head) 614 

141. — Method of palpation in eliciting tenderness in the kidneys . 615 
142. — Position assumed in kidney disorders, ureteral and kidney 

colic, lumbago, uterine and tubal adhesions and drag on 

back, enteroptosis, especially after removal of corset . 617 

143. — Area of hyperalgesia in congestion of kidney . . . 631 
144. — Areas of hyperalgesia in congestion of kidney associated with 

liver congestion : Anterior view ..... 634 
145. — Areas of hyperalgesia in congestion of kidneys associated with 

liver congestion : Posterior view ..... 634 

146. — Area of hyperalgesia in kidney and liver congestion . . 635 

147. — Area of hyperalgesia in nephritis ..... 636 

148 and 149. — Areas of tenderness present in renal tuberculosis . 643 

150. — Areas of distribution of anterior spinal nerves . . . 660 

151. — Areas of distribution of posterior spinal nerves . . . 660 
152. — Head zones of hyperalgesia usually associated with kidney 

lesions : Anterior view ....... 661 

153. — Head zones of hyperalgesia visually associated with kidney 

lesions : Posterior view . . . . . . . 661 

154. — Area of cutaneous hyperalgesia in severe renal colic in which 

the stone was in the ureter ...... 662 

155. — Pressure made upon ureter in endeavor to obtain local ten- 
derness ......... 663 

156. — Toumier's points of pressure in kidney and ureter lesions . 664 
157. — Relationship existing between pain and other sensations aiising 

in the urinary bladder ....... 673 

158. — ^Pain areas associated with diseases of bladder . . . 674 

159. — Relationship of rectal tenesmus to vesical tenesmus . . 675 
160. — Areas of referred pains usually associated with disease of 

urinary bladder ........ 676 



161. — Referred pain in disease of bladder . . " . . . 677 

162. — Referred pain in disease of bladder 677 

163. — Referred pain in disease of bladder ..... 677 

164. — Referred pain in disease of the bladder due to involvement of 

the pudic nerve ........ 679 

165. — Areas of cutaneous tenderness in disease of the epididymis . 699 
166. — Areas of distribution of the tenth and eleventh dorsal segments, 
and the first, second and third sacral segments on the 
right side ......... 701 

167. — Nerve supply of female genitalia ...... 706 

168. — ^Area of distribution of cord segments involved in uterine, 

ovarian, and tubal diseases ...... 714 

169. — Points of tenderness as elicited by Donald and Lickley in 

ovarian, tubal, and uterine diseases .... 720 

170. — Areas of hyperalgesia in a woman two months pregnant . 736 
171. — Phenomena accompanying tubal disorders . . . . 738 

172. — ^Areas of referred pain in a case of labor .... 740 

173. — Areas of cutaneous distribution of the thoracic segments . 761 
174. — Points at which the intercostal nerves become superficial . 763 
175. — Location of tenderness in various diseases of the chest and 

abdomen ......... 765 

176. — Location of hyperalgesic zones and the areas of pain in cardiac 

and aortic lesions ....... 775 

177. — An area of hyperalgesia corresponding to portions of the sec- 
ond, third and fourth dorsal zones .... 776 

178. — Areas of cutaneous and deeper hyperalgesia in a case of acute 
dilatation of the heart, accompanied by acute distention of 
the liver ......... 777 

179. — Hyperalgesic area in a case in which the myocardium is prob- 
ably in a state of intoxication ..... 778 

180. — Areas of pain in a case of mitral and aortic regurgitation . 779 
181. — Area of sensory disturbances in a case of angina pectoris . 785 
182. — Communication between spinal accessory and vagus . . 786 

183. — Emergence of the spinal accessory from under the sterno- 

mastoid . . . . . . . . . 787 

184. — Conducting paths for impulses from the heart . . . 788 
185. — Points of emergence of the dorsal nerves (anterior) . . 791 

186. — Areas of hyperalgesia in a case of diaphragmatic pleurisy . 793 
187 and 188. — Areas of referred pain in pleurisy .... 794 

189 and 190. — Figures showing, on the left side, the areas of distri- 
bution of pain in a case of diaphragmatic pleurisy with 
effusion ; on the right, the areas before the effusion ap- 
peared ......... 796 

191. — Some of the areas of pain and tenderness in cardiac and pul- 
monary disease ........ 801 




To those who are interested in the study of disease, it is 
scarcely necessary to emphasize the value of the correct apprecia- 
tion of pain as a symptom. The importance of its interpretation 
must be obvious. Almost ninety per cent, of all diseases either 
begin with, or have, pain as a prominent symptom at some time 
during their course. Therefore, a correct diagnosis can hardly be 
made without an intensive study of the various forms of pain. 

Sensation in Lower Animals. — We may, therefore, take up 
with profit a consideration of sensation, of which pain, as a psycho- 
logical entity, is but a part. In fact, to gain a comprehensive 
idea of pain, it is necessary to begin our studies with those organ- 
isms in which sensation emerges from that simple state in which 
all stimuli are responded to by reflex protoplasmic movements, of 
which the organism has no perception. 

This movement according to Loeb would be the result of che- 
motropism. All protoplasm is attracted by certain substances and 
repelled by certain other substances, the attraction and repul- 
sion depending upon the construction of the protoplasm and the 
stress of its need or avoidance of the constituents of which the 
other body is composed. Such a state we find in the ameba. In 
a higher organism, as the medusa, an aggregation of cells possesses 
the same threshold of irritability for certain substances and thus 
they respond to irritation by coordinated motion and this seems 
to be due to the presence or absence of certain ions in the stimu- 



lating substance. (Na ions start or increase rhYthmical contrac- 
tions; Ca diminish, the rate or inhibit such contractions.) Or 
should the cells all not come into contact with the exciting factor, 
the one coming into contact can transmit its stimulus to other 
adjacent cells and in them produce a similar reaction to its own. 
This propagation by contraction is better exampled in the 
Ciona intestinalis, where as a means of communication a set of 
cells are specially differentiated so that they can better and more 
quickly carry stimuli from one structure to another. In other 
words, conduction is their function. These cells arrange them- 
selves into special gi'oups, etc., and form what is termed the nerv- 
ous system. But in the lowest forms of life the nervous system 
is not a necessity, but only an auxiliary in the life economy of the 
animal, as demonstrated by Loeb. He removed the central 
nervous apparatus of the Ciona intestinalis and found that it 
still responded to a mechanical stimulus of one group of muscles 
by contraction of other groups, but that this response was much 
slower than when the central nervous system was intact. From 
this he concluded that while the central nervous system was not 
absolutely necessary (in this animal) still it served a useful pur- 
pose in that the stimuli were conducted more quickly and that 
therefore the threshold of response was greatly lowered. In the 
earthworm, which is composed of segments, each segment has its 
own special nerve supply. Forward motion in this animal is due 
to the alternate action of the longitudinal and the circular mus- 
cles. Friedlander found that removal of its central nervous sys- 
tem had no effect on the coordination of progTessive motion. 
This is explained by Loeb, who says that when the forward piece 
is elongated and attempts to shorten itself by contraction of the 
longitudinal muscles, the skin of the aboral piece is stretched and 
that this stretching produces a stimulus to the longitudinal mus- 
cles of the posterior piece which then contracts and causes the 
animal to move forward. Thus at this stage of biologic advance- 
ment, motion is not the result of sensation, but is only a reflex of 
a very simple nature. In animals of a higher order the same 
stimulus exists, but the stimuliLS of origin is in some cases far 


removed from the stimulus of effect. The conduction from place 
of origin to point of effect being through nerve paths, the motion 
is still the result of a reflex, and this reflex either causes the ani- 
mal to move to or draw away from the source of the stimulus 
either as it is beneficial or destructive to its economy. When it 
does so withdraw or when it responds to excitor stimuli by rapid 
and irregular motion, are these an indication of a disagreeable 
sensation or of pain ? 

Reaction of Animals to Pain. — Many have assigned to the 
lower organisms the same pain sensation as that possessed by man. 
The reason assigned for this hypothesis is that reactions take 
place to injurious stimulation, by various reflex movements, and 
that these reflex movements are the motor manifestation of pain. 
This interpretation is contested by l^orman ("American Journal 
of Physiology," Vol. Ill, p. 271, 1899), who states that in many 
animals, ranging from the simple worm to the higher vertebrates, 
such as fish, he has cut off segments of the body and otherwise 
insulted the integrity of the structure, without, in some instances, 
producing any movement at all, or, if movement occurred, with- 
out producing any which was greater than that caused by ordinary 
and slight stimuli. He maintains that the movement of an ani- 
mal is not due to impulses caused by the sensation which we desig- 
nate as pain. Should excessive reflex movements be produced, 
they are the result of an excess of stimuli, not necessarily destruc- 
tive. His experiments were varied and numerous. In one in- 
stance, he cut an earthworm in two ; and while the posterior part 
performed very rapid twisting and squirming movements, the 
anterior half simply elongated and went on crawling, the same as 
before the experiment. Is it possible that pain would be felt in 
the posterior part, and that the anterior segment, in which the 
main ganglia are located, would be free of pain ? !N^orman 
elaborated his experiments further. He cut in half a leech, which 
was swimming in the water, and observed that both segments 
continued their motion without interruption. Starfish and crabs, 
as well, showed no reaction to division. He cut away the posterior 
part of the abdomen of a bee, while it was engaged in sucking 


honey, without any interruption to its activity. He also men- 
tions the fact that sharks may be cut and operated upon without 
the slightest movement on their part. Experiments of this nature 
tend to show that one must ascend rather high in the vertebrate 
scale before true pain phenomena make their appearance. In 
fact, it is only iij mammals that this sensation is developed to its 
highest degree. In our study of pain, therefore, we must bear in 
mind that motor response to an irritant is not always an indi- 
cation of pain, but is only a reaction to stimuli (not necessarily 
sensory). However, before proceeding further in our considera- 
tion of pain phenomena we shall study sensation and its attributes. 
General Consideration of Sensation. — Sensation itself is 
the perception of an impression conveyed to the brain as the result 
of the activity of some peripheral sense-organ. These sense-organs, 
may give rise to both subjective and objective sensations. Sub- 
jective sensation is the result of activity of those forces of the 
body which are concerned with its integrity and well-being. It 
gives rise to hunger, satiety, nausea, thirst, physical or mental 
depression, or exhilaration, joint sensation, and the like, and may 
be called an organo-protective sensation. It also produces the 
feeling of fatigue and exhaustion. Objective sensations primarily 
depend, for their perception, upon the presence of external re- 
ceptors, such as those of sight, touch, smell, hearing, taste, tem- 
perature, etc. Therefore, in order to have sensation, that is, to 
be capable of perceiving and interpreting stimuli, and of classi- 
fying them under certain empirical divisions as belonging to one 
domain or another of feeling, it is first necessary that our sense- 
receptive organs be intact, the sense-conveying organs normal, the 
sense-interpreting centers active and the associative memory cen- 
ter (consciousness) intact. Should the latter be disturbed, as oc- 
curs during certain mental diseases, anesthesia, etc., sensory stim- 
uli, irrespective of their character, either will fail to be jDcrceived, 
or, if they are, will be greatly modified. Since we speak of con- 
sciousness it may be well to briefly consider it. It has been de- 
fined as the ability, power, faculty, or mental state of being aware 
of one's own existence, thoughts, feelings, actions and sensations, 


whether intellectual, moral or physical (Sudduth, 472), and must 
be present to take up and correlate the different stimuli reaching 
the brain from the periphery. 

Consciousness has been divided into two classes: (a) subjective 
and (b) objective. Subjective consciousness tells us of things 
which originate in the mind (we shall have occasion to use this 
concept later in our study of hysteria). Objective consciousness 
tells us of things perceived through the senses. 

Of the senses we distinguish two varieties, the internal and 
the external. The internal senses are those which are concerned 
with the well-being of the organism, and the relation of the dif- 
ferent parts, one to another. They include muscle sense, joint 
sense, hunger sense, etc. The external senses are those which 
are concerned with the interpretation of external objects, and in- 
clude, generally speaking, touch, smell, sight, hearing, taste, mus- 
cular and temperature sense. Each of these senses has a complete 
nerve apparatus of its own, consisting of sense-receptive, sense- 
conveying, and sense-perceptive organs. The sense-receptive or- 
gans are the terminal filaments of the sensory nerves. The sense- 
conveying organs are the axis cylinders of the sensory ganglia cells 
(the nerves) and the sense-perceptive organs are the sensory cor- 
tical cells. 

We now have the apparatus ; all that is lacking is the force. 
The question now arises, what is this force, and what varieties of 
stimuli produce the changes which give rise to sensation ? The two 
most prominent hypotheses are that the. stimulus is of a chemical 
or electrical nature or is a mechanical force in the form of vibra- 
tion. The chemical hypothesis is that the external stimuli produce 
some chemical change in the cell, which reaction is propagated 
into other adjacent cells until it reaches the perceptive center. 
Engelman (377) advances the idea that the impulse which cre- 
ates sensation is of an electrical nature, but does not exactly de- 
fine what he means by electrical nature. By many, however, it 
is held that all sensation is the appreciation of arrested motion 
(vibration), this motion being the result of a mechanical, a chem- 
ical or an electrical contact. It is the motion of the ether mole- 


cules "upon the retina which produces the "formation or decom- 
position of certain substances and it is the chemical processes of 
the formation and decomposition of these substances which deter- 
mine light and color sensations" (Loeb, 104 C, p. 291) ; the mo- 
tion of the air molecules upon the drum membrane of the ear 
which "causes vibration in endings of the auditory nerve by which 
new molecules are brought into contact with each other and 
sound is produced" (Loeb) ; the impact of the odoriferous parti- 
cles upon the olfactory nerve terminals in the mucous membrane 
of the nose which creates smell (chemical action). For taste, it is 
essential that the sapid substance shall come in contact with the 
taste-buds of the tongue (chemical action) ; for touch, that matter 
must come in contact with the nerve terminations in the skin. Thus 
we see that all sensation depends upon contact, and that contact 
gives rise to motion. This motion is in the form of vibration 
(molecular), and the sensation produced depends upon the sense- 
- organ against which the vibration impinges. Each terminal sense- 
organ takes up only the vibrations produced in a particular me- 
dium. For instance, in the normal state, sound is perceived only 
when the air is in vibration against the cochlear apparatus ; light 
depends wholly ujDon the vibration of the ether ujDon the retina; 
smell upon the impingement of minute physical particles upon 
the olfactory terminals, etc. It is also of great interest to know 
that the sense perception of these organs in man is limited to the 
perception of vibrations which lie within certain limits. For 
example, the human ear is unable to hear if the vibration is 
below two per second, or greater than thirty-three thousand per 
second. Thus man is unable to hear the calling of a whale, be- 
cause the tone of the whale's voice vibrates only two per second; 
as he also frequently is unable to hear the humming of a swarm 
of gnats, a sound which is produced by a vibration of about thirty- 
five thousand per second. 

Properties of Sensation. — Sensation possesses the following 
properties: quality, intensity, and duration. 

(1) Quality gives us an idea as to the cause of the sensation. 
For instance, the quality of the sensation of sound is entirely dif- 


ferent from that of the sense of taste, and it is this difference 
which enables us to correctly determine the source of origin 
(whether from a perij^heral sense-organ of taste, hearing, smell, 
etc.). It also enables one to distinguish variations in the same 

(2) Intensity enables us to distinguish differences in the 
strength of stimuli producing the same sensation, and indicates, 
also, the receptive state of the organism to the sensation. At cer- 
tain times pain is much more acutely felt. This is due to the 
fact that at these times the organism is weaker, being either re- 
duced by exhaustion or disease, and therefore it is more acutely 
affected by all irritative stimuli. 

(3) Duration of a sensation depends, first, upon the inten- 
sity, and second, on the rapidity of the impulse. If the impulse is 
very intense, the sensation in the sense-perceiving centers persists 
for some time after the stimulus has ceased. For example, if a 
bright light is placed before the eyes, the sensation of light per- 
sists for some time after the light stimulus has been removed ; also 
if we gaze at a bright light and then close the eyes, the sensation 
of light still continues for a few seconds. The rapidity of the 
rej)etition of stimuli also influences the duration of the sensation. 
If the stimulus is repeated too frequently, we find that a continu- 
ous instead of an interrupted sensation is felt. This is due to the 
fact that the sense perception of all stimuli persists for a short 
time after the stimulus has ceased to exist. Thus, if the stimuli 
follow each other at short intervals, the sensation is that of a con- 
tinuous stimulation. At times, remissions in sensation occur, and 
are due to fatigue of the central sense-perceiving center. 

Centers for Sensory Perception and the Sense- Organs. — It 
has been observed by Goltz, H. Munk and others (Tigerstedt's 
"Physiology," p. 651), that in the dog the destruction and 
removal of the motor region and the cortical layers adjacent 
thereto cause a variety of derangements of sensation and of mo- 
tion. These cortical layers, then, must in some manner be con- 
cerned with the perception of sensation. It has been found that if 
the entire cortical area for the posterior extremity is removed the 


muscles of the opposite leg can no longer execute finely graded 
movements ; that for some days after the operation a complete 
insensibility in this extremity exists; and that a certain hlunt- 
ness of sensibility becomes permanent. 

With still more extensive destruction, the finer movements of 
the hand and foot are permanently arrested in the monkey, 
and for some time after the operation the sensitiveness of the 
paws is somewhat reduced, so that the animal reacts only to very 
painful stimuli. In fact, the sensitiveness of the hand and foot 
becomes permanently so slight that a severe pinch produces no 
reaction at all (Mott). On the other hand, SchafFer has found 
that a monkey which does not react at all to a painful pinch im- 
mediately notices a slight tactile stimulus applied to the para- 
lyzed extremity. The monkey from which Goltz had removed 
the entire motor region of the left hemisphere took no notice of 
the gentle tactile stimuli applied to the right extremity. 
Stronger pressure stimuli were always felt. Motor sensations 
were also somewhat diminished. 

From this it will be observed that generally, except in the 
case mentioned by Schaffer, in which pain sensation was lost 
but tactile sensation was present, it will be found that, in case 
of destruction of the motor area, the sensation in the skin over 
the paralyzed part will also be reduced for touch, but present 
for pain. This might be accounted for on three hypotheses: (1) 
that the impulse which would produce pain is so intense that it 
spreads over a considerable area of the cortex, and is communi- 
cated to parts which are not destroyed and which still have the 
power of pain perception; or (2) that, owing to the strength 
and volume of the impulse, it is transmitted to the cortical area 
in the opposite hemisphere, and is there perceived; (3) that 
the center for pain sensation is not in the cortex, but lies proximal 
to it in one of the forwarding structures of the sensory apparatus, 
namely, in the optic thalamus. The first supposition gives weight 
to the argument that it is the extent of the cortical reaction which 
produces the relative sensations, either of touch or of pain, a small 
area giving rise only to touch, a large area to pain. This possibly 


General Sensation Touch 


Fig. 1. — Right Cerebral Hemisphere Seen from the Outside. 

General Sensatiofl 



Fig. 2. — Inner Surface of Right Cerebral Hemisphere. 
Figures 1 and 2 show the areas of sensory distribution according to Tiger- 
stedt (p. 654), modified from Flechsig. Dots indicate sensory areas. 
Areas where dots are thickest are the regions where most of the sensory 
pathways end. 



can be explained from the inhibitory action of the cortex, the 
destruction of a small area being not sufficient to abolish the in- 
hibitory impulses sent from the cortex to the optic thalamus and 
their acting as controls over the sensory perceptions. 

It has been found that general sensation and touch are lost 
by destruction of the central and parietal convolutions, paracen- 
tral lobules, and possibly the posterior part of the frontal convo- 
lutions, and that, for the most part, the sensory area consists of 
post central and parietal convolutions (Leszynsky, 498; May, 
397, p. 793). 

Many sensory fibers enter the post central convolution. Some 
also enter the precentral convolution. The first and second frontal 
convolutions also receive some fibers; they chiefly are, however, 
sensory fibers connected with the cerebellar system. 

Upon destruction of these areas, the different sensations are 
differently affected, namely: (1) pain sensations suffer least, 
because a wider area is required for their destruction; (2) pres- 
sure and temperature sensations are somewhat reduced, but by 
no means abolished ; ( 3 ) power of localization is profoundly 
affected; (4) motor sensations are much disturbed. 

The areas for sensation are probably bilateral in their loca- 
tion. Mills claims that they are also found in the limbic and 
quadrate lobes. While Dana admits that this is possible, he 
also holds that the motor areas are also sensory (Church and 
Peterson, 506, p. 367). The sensorimotor area, in the optic 
thalamus (the so-called associative memory center of Loeb), is 
probably a depot for memory of sensation as it passes on its way 
to higher centers, in the limbic or quadrate lobes. 

According to Horsley (ibid., p. 162), the different cell areas 
for motion and sensation are superimposed in strata. Most super- 
ficially the tactile sense, then the muscular sense, and finally the 
pure motor sense elements are found. It appears that in these 
areas the granular cells are the active agents in sensory percep- 
tion, since lesions in this cell layer cause disturbances of touch, 
pressure, localization, muscular sensibility (sense of passive posi- 
tion and of movement), and, less frequently, of pain and tem- 


perature. This disturbance occurs in the opposite side of the 
body, and, when a limb is involved, the sensation is first lost in, 
and is last to return to, the distal portion and outer margin (W. ' 
Page, May, 397, p. 796). 

The small pyramidal cell layer may also be concerned indi- 
rectly in pain production, since these cells are atrophied in 
dementia, and may, therefore, be indirectly associated with sensi- 
bility; because it has been found that sensibility varies almost 
directly in proportion to the mental development of the individual, 
and that the pyramidal cells vary directly in proportion to the 

It has also been claimed that the cerebellum is the seat of all 
pleasure and pain activities (F. Courmont, "Le Cervelet et ses 
Fonctions"), and also of those connected with the emotions 
(Marshall, p. 25). Modern anatomical research, however, has 
shown that the cerebellum is the chief central organ for the senses 
of equilibrium, muscle tonus, and orientation in space. And al- 
though it is preeminently a sensory organ, the cortex being a 
sensory cortex, it is not such for pain, for light touch, heat, or 

Sense Perceptive Organs. — Recently the sense-organs, the 
stimulation of which causes sensation, have been divided into 
three classes: (1) the visceral sense-organs of the internal organs 
and their derivatives, (2) the extroceptor, or somatic, sense-organs, 
which receive the impressions from the outer world, and (3) the 
proprioceptors, which receive impressions from the muscles, ten- 
dons, etc., and report to the sensory area the exact position of the 
body and the relationship of parts to each other. 

The researches of Head, Holmes, and Sherrington have served 
to show that the constituents of sensation are extremely complex. 
So far as the visceral receptors are concerned, we know very little 
about them. There are chemical, touch, heat, and cold receptors, 
and undoubtedly receptors which have to do with the forces of 
gravity. Most of these receptors Head has placed within his ])ro- 
topathic system. They belong, phylogenetically speaking, to old 
systems; are almost automatic, and for the most part are passed 


over to the autonomic sympathetic nervous system. Their spinal 
representations are present largely in the lateral processes of the 
cord. Their central paths are not as yet definitely determined. 

The extroceptor or somatic sense organs are divided by Head 
into the epicritic and protopathic systems. The ability to dis- 
tinguish light touch (cotton wool), two points of a compass (at 
small intervals varying with the part), and to discriminate slight 
variations in temperature, are held by Head to be specific and in- 
dividual entities. Together they constitute his epicritic system. 
Their spinal, medullary, thalamic, and cortical distributions have 
been fairly well defined. To the protopathic system on the 
other hand belong the faculties to distinguish ordinary touch, deep 
pressure, extremes of heat and cold. Finally, according to Sher- 
rington, there exists another system, the proprioceptive. Its re- 
ceptors are found in many places in the body, chiefiy in the ten- 
dons, muscles and bones, and also most characteristically in the 
labyrinth. Its chief sensations are those connected with the orien- 
tation of the body in space; the vestibular nerve being its chief 
cephalic ganglion and the cerebellum its chief central organ. 

Stimuli. — The stimuli necessary to produce a sensory-reaction 
may be mechanical, chemical, thermal or electrical. Any of these, 
when applied in normal quantity, and with normal force, produces 
a normal reaction; but when applied with excessive intensity, all 
are capable of stimulating the specific pain receptors. 

Interpretation of Sensation. — If we consider for a moment 
the embryological development of the human body, we find that 
the external organs of sensation develop pari passu with the in- 
ternal organs, but that the external ones are practically without 
function until the fetus is born. During the period of intra- 
uterine existence, the external senses are lying dormant; but as 
soon as the fetus is born, and feels the touch of air upon its sur- 
face, it has entered upon a new life, and one vast complex of 
sensations reaches it from every side. Embryologically the vesti- 
bular system develops very early. 

These sensations are for three purposes: (1) to provide pro- 
tection for the organism; (2) to provide for its development; and 


(3) to provide for its reproduction. We find that in general 
everything which reacts unfavorably to the organism causes dis- 
tasteful and disagi-eeable sensations. These, when of a peculiar 
quality and intensity, give rise to the sensation which we term 
'pain. It is also found that everything which acts or aids in the 
growth, development and reproduction of the organism causes 
pleasure. Between the two extremes of pain and pleasure there 
exists a neutral state, where, because of the weakness of sensory 
stimulation or perception, a state neither of pleasure nor of pain 
is produced. This we term the state of indifference. Therefore,' 
we may be said to have three states of sensory mental activities, 
namely, pain, indifference and pleasure. 

Definition of Pain. — Pain is distinctly a mental interpre- 
tation, and cannot be strictly defined. It is the interpretation of 
some abnormal and generally harmful process which is occurring 
in the organism. It cannot be classed as a sensation, but rather 
is the result of the perception and interpretation of sensation by 
the mind. Our consideration of pain will naturally lead us into 
a discussion of its antithesis, pleasure, since the two are inti- 
mately connected in their perception and in their interpretation. 
Both are the result of mental activity. 

Mental Activity. — According to many authors, three divi- 
sions of mental activity have been assumed : intellect, or the 
faculty of thought ; sensibility, or the faculty of feeling, and voli- 
tion, or the faculty of voluntary action. This is manifestly a 
purely artificial division. While we are primarily interested with 
the second division, it is my purpose to show that it is intimately 
bound up with the first (intellect). I shall also point out that the 
intellect can, by the exercise of memory, recall to mind the ob- 
jective sensations classified as pain, and, by making them perti- 
nent to the moment, cause them to appear real, as if experienced 
at the time. In other words, intellect is able to produce, without 
any objective means, the sensation of pain. This class of pain- 
sensation, which seems to appear without any definite causative 
factor, is frequently called subjective pain. 

The crudest mental impressions consist of the primary sensa- 


tions of touch, sight, hearing, taste, smell, and temperature, which 
are objective, and muscle sense, joint sense, hunger sense, etc., 
which are subjective. These, when carried to and interpreted by 
the brain, result either in pleasure sensation, neutrality, or pain; 
and as a result of these mental interpretations there arise certain 
mental states, such as joy, sadness, pleasure, and happiness, which 
in turn may give rise to mental activities, such as anger or its 

Mektal States. — I do not mean to say that all sensation 
must definitely be interpreted either as painful or as pleasant, in- 
asmuch as there are sensations which are neither painful nor 
pleasant. These are referred to as neutral sensations, For in- 
stance, the sight of a tree may be neither pleasant nor painful, 
but the recollection of certain facts associated with that particu- 
lar tree may recall, at the sight of it, certain thoughts that induce 
a painful or rather unhappy emotion; and here it is well to dif- 
ferentiate emotion, which is a mental state, from pleasure-sense 
or from pain, which are but sensations. Ideas or thoughts may 
give us pleasure, but it requires an external stimulus to arouse 
the pleasant sensation that may accompany thought, such as is 
found in reading, in listening to sounds which are pleasant when 
grouped in the form of harmony, in hearing beautiful ideas well 
expressed, or in seeing wondrous j)roductions of blended colors 
in the form of a beautiful landscape. Therefore, the use of the 
word pleasure should be restricted, I think, to the mental state 
following upon pleasant or agi-eeable sensations, which, in turn, 
should be called pleasure-sensations. Thus we have the emotional 
condition of pleasure and of its converse, displeasure. 

Mentax, Resultants. — From every mental state, certain de- 
rivatives arise; for instance, anger is often evolved from dis- 
pleasure. Mobile pleasure gives rise to elation. It is the affective 
state which we are in that colors our perception and guides our 
acts; and it is particularly fitting, in this connection, that physi- 
cians should bear in mind that the fundamental cause of an ill- 
behaved, crabbed disposition very often is to be found in the 
elementary sensations coming from the periphery, acting as ex- 


citors to a possibly already overwrought and abnormal nervous 
system. How easy it is, on this hypothesis, to account for the 
sour and surly disposition of the dyspeptic, or the forbidding as- 
pect of the chronic sufferer. They are worthy of our kindest con- 
sideration, for their disposition and their evil manners are often 
due to causes over which they have little control. 

EELATioisr OF Paiist and Pleasure to Mental States. — Ac- 
cording to Marshall, pleasures and pains are but differential quali- 
ties of all mental states. To this I must take exception, for, to 
my mind, they are but interpretations of sensations which are 
perceived as arising in the periphery. 

It would seem more fitting that pleasure, when applied to sense 
perception, should be spoken of as pleasure-sensation. For in- 
stance, a cool bath taken on a warm day gives rise to a pleasant 
sensation and at the same time produces pleasure; but thoughts 
of an absent one, or of some joyous past event, may give pleasure, 
while at the same time we have no pleasant sensation. 

ISText it behooves us to ask, can both pleasure-sensation and 
pain be perceived at the same time, and, if they are not perceived 
and factors which ordinarily produce them are present, is their 
non-perception due to the fact that they neutralize each other? 
It is inconceivable that two such opposites as these could exist in 
consciousness at the same time ; and it is entirely improbable that, 
should such a state exist, their contra-action would produce a con- 
dition of neutrality, which is the result of two active, equal and 
opposing forces. Por instance, the distress which comes from an 
ulcerated stomach or an irritated sore cannot be neutralized by 
the physical pleasure derived from epidermic sources. We experi- 
ence either pleasure or pain; there is no halfway stop where the 
one counteracts the other, giving rise to a state neither of pleasure 
nor of pain, but of neutrality. Yet, in some cases a transition 
from pleasure to pain-sensation may occur, for it is found that 
sensations which ordinarily are interpreted as pleasant may, from 
frequent repetition and excessive stimulation, become painful, as 
in pericementitis, in which at first a pleasant sensation is pro- 
duced on lightly pressing the teeth together, but which, if the 


pressure is continued or increased, results in pain. Another ex- 
ample is priapism, in wMcli the distention, which at first is pleas- 
ant, if continued, soon becomes painful. Gentle friction over the 
body, especially over the nape of the neck, is pleasant (to most 
people) ; yet, if the friction becomes excessive, and the nerve- 
endings are irritated, the pleasant sensation is transformed into 
a painful one. Again, a harmonious play of colors is soothing and 
pleasant to the eye ; but let the colors be exceedingly brilliant, the 
pleasant sensation is transformed into a disagreeable and painful 
one. Another example may be deduced from the sense of hear- 
ing. We all knov7 how pleasant to the ear are the tones of a harp ; 
but change them into the shrill notes of the siren and we almost 
shriek with pain, or rather let us say distress. Yet, if now we 
modify the vibrations and reduce them in number, the distress 
disappears ; and the sound, while neither painful, nor pleasant, 
may become pleasant if we place among its components some half 
tones which increase the fullness and volume. These are examples 
of sensations changing from pleasant to painful, and then back 
again from painful to pleasant. The changes which bring this 
about are the result of variations in the force and rapidity of the 
impulses impinging on the nerve terminals. 

Certain laws have been deduced from this transitional inter- 
pretation of impulses from pleasure to pain, of whicji the two 
following are taken from Moher (''Psychology," p. 225), who 
says that: 

(1) Pleasure is an accompaniment of the spontaneous and 
healthy activity of our faculties, and pain is either the result of 
their restraint or of their excessive exercise. 

(2) Pleasure increases with increasing vigor in the opera- 
tion, up to a certain normal medium degree of exertion, and pro- 
gressively diminishes after that stage is passed. Farther on, 
pleasure disappears altogether, and beyond this line pain takes its 

Whether this interpretation is correct is not yet apparent. If 
the receptors for light and sound, for example, have specific pain 
receptors, which have a definite threshold value and only react 


when the intensity of the stimulus has reached a definite point, 
then the older hypothesis that assumes that pleasure passes into 
pain fails. By bearing in mind the analogies in skin sensibility, 
it would appear that such specific receptors are probably present, 
and recent studies of sensation tend to show that they are pres- 
ent and are independent of others of a lower threshold value. 
Should this principle hold true for the sensory systems through- 
out, epicritic and protopathic, our conceptions of pain and its re- 
lation to pleasure will be markedly altered and simplified ; we then 
may discard much of the metaphysical speculations regarding the 
relations of pleasure and pain. These, however, will be discussed 
more fully in another chapter. 



Definition. — Various definitions of pain have been given by 
different authors. Meade says that pain is an indication of inter- 
ference with the power of nutrition of the organism; pleasure, 
of the elevated power of nutrition of the organism. Gilman thinks 
that the source of all pleasure is the renewal, on the part of the 
nerves, of the activity that has already become familiar to them, 
while pain has its source in the violation of nervous habitude. 
Meynert and Gilman think that the effective working of the 
psychic functions is the cause of pleasure, while any obstacle to 
these functions is the cause of pain. Sidney E. Mezes says that 
pleasure is attention without difficulty or obstruction, while pain 
is attention with difficulty. This applies to mental pleasure par- 
ticularly, as close attention with deep thought is pleasant, while 
obstruction to this attention and thought, due to internal conflict, 
distress of mind, or other causes, is painful (Bianchi, p. 346). 
Bianchi further says that whenever there is internal emotion, or 
exteriorization, in response to the needs of life, there is pleasure ; 
when the movement is hindered or obstructed, there is pain. This 
applies particularly to hunger pains. 

The aspect theory, as held by C. D. Strong (473), regards 
pain as the highest degree of displeasure, and holds that the pain 
of a cut or of a burn can always be analyzed into a tactile or tem- 
perature sensation, on the one hand, and a feeling of displeasure 
on the other. Kulpe evidently was the inspiration for this idea, 
for he is quoted by Strong as saying that "the characteristic fea- 
ture of pain is not the sensational quality, which is never absent, 
but the feeling of the disagreeable, of which pain is the highest 


degree." On the other hand, Lehmann does not entirely lose 
sight of the sensational element of pain when he says : "A feel- 
ing, whether of pleasure or of pain, never occurs apart from a 
sensation, however weak, and in every case where such an isolated 
feeling is supposed to have been observed, the sensational element 
has merely been overlooked." 

Meyers (122, p. 744) says that pain is a beneficent reaction, 
through the nervous system of altered structure or disordered 
function, against threatening forces. Dunglison, in 1857, defined 
pain as "a disagreeable sensation which scarcely admits of defi- 
nition" — truly a very indefinite definition. Quain (471), not 
more clear, said that "it is the representation in consciousness of a 
change produced in a nerve center by a special mode of excita- 
tion." Sudduth says that "pain is a mental state, an element of 
consciousness, due to the perception of an injury to the body or 
to the feelings." By this definition it is seen that Sudduth holds 
that there must be a condition of mental aptitude or perception, 
for otherwise it is not possible to decide as to whether or not an 
injury is painful. 

Schopenhauer turns to scholastic philosophy and the intro- 
spective method of deduction, for he believes that "pains are 
positive and pleasures are negative experiences ; pleasures are due 
to the absence of pain, and the intensity of one is often in propor- 
tion to the other feeling that preceded it." Another definition, 
of somewhat the same character, is given by Spinoza, who says 
that "pleasure is an emotion whereby the body's power of activity 
is increased or helped, and pain is an emotion whereby the body's 
power of activity is diminished or checked. Therefore, pleasure 
in itself is good." (Spinoza's "Improvement of the Understand- 

As one retreats farther into the past, it will be seen that the 
physical properties of pain were not perceived, and that only 
a metaphysical interpretation was taken into consideration. 
The early Celts and Teutons had a mythological representation of 
disease, called Hela, a ghastly form who received all who died 
of disease into her residence, Niflheim. In this were the Hall 


Elidnir (pain), her bed, Koer (disease), and tiie table, Hungur 
(Allen, 510). Cicero described pain as a disagreeable move- 
ment in the body (35) ; Gambuus called it a disagTeeable sensa- 
tion which the mind wonld rather not experience ; while Sauvage 
spoke of it as a disagreeable sensation originating from any lesion 
of nerve fibers (5). Valentine (507), Wundt (508) set forth the 
idea that too great an intensity of stimnli may cause pain; Erb 
held that every increase of sensory stimuli is capable of producing 
pain as soon as it attains a certain intensity; Eulenburg (509) 
states that it is a gTadual increase in the feeling which accom- . 
panics every sensory process. 

Erom the j)receding, we see that there are two ideas underly- 
ing the various definitions for pain ; the one physical and the other 
metaphysical. The older writers dwelt upon its psychological as- 
pect, namely, that it is a disagTeeable sensation, while the modern 
thinkers add that the disagTeeable sensation is the result either 
of lessened nutritive activity in the cell (receptive or perceptive), 
or is the indicator of the reaction against whatever tends toward 
the destruction of the organism. 

Universality of Pain. — As an evidence of the universality of 
pain, we find words expressing it in all languages; and as an evi- 
dence of the antiquity of its existence, we find that the word ex- 
pressing it is practically the same in all languages having a com- 
mon origin. In the English language, the name is probably de- 
rived from the Middle English, and is a term used to convey the 
idea of suft'ering. This, in turn, like a similar expression 
found in all modern languages, was probably derived from 
the Latin poena, which means a punishment, and which no doubt 
originated in the Greek word Trotva also meaning a punishment or 

Metaphysical Consideration of Pain. — Thus far we have been 
considering pain as a sensation. This, according to Marshall 
("Pleasure and Pain," p. 25), is untenable, for the following 
reasons : 

A sensation must have a receptive, a conducting, and a per- 
ceptive organ and 


(1) Ko center for pain has ever been defined or located. ■*■ 

(2) ISTo special means for pain production are present, as in 
the case with other sensations. 

(3) Pain is aroused by the most varied stimuli, while sensa- 
tions are aroused by well-defined and limited stimuli, which must 
be exerted upon a special sensory-perceptive apparatus. 

(4) Sensations are themselves both painful and pleasant; 
therefore, pain and pleasure are but attributes of sensation, and 
cannot exist by themselves as separate sensations. For instance, 
heat, cold, taste, smell, hearing, and sight may all be painfully, 
as well as pleasurably, perceived. 

(5) Pain may exist in the intellect without any peripheral 
cause, but in this case it generally acts as a qualifying factor in 
emotion, which is a mental state. It is extremely difficult to say 
whether an abstract idea can or cannot be painful. Perhaps the 
most we can say is that it is either agi-eeable or disagreeable. 

(6) Another argument sometimes advanced against pain be- 
ing a distinct sensation is that we can draw up in the imagination 
a representation of sensation without its actual presence; but we 
cannot, by any stretch of the imagination, conjure a picture of a 
pain, but must always associate it with some sensation, such as 
touch, heat, cold, etc. 

!N^ewer research has shown that Marshall's position is abso- 
lutely untenable, but we shall for a moment discuss its merits and 
demerits, with the hope of adding light to the whole subject. With 
regard to Marshall's first proposition, that no center for pain has 
ever been defined or located, it may be said that w^hile, as a rule, 
physiologists and psychologists do not limit pain perception to a 
particular region of the brain, they hold a rather unanimous belief 
that the sensations, of which pain constitutes a part, have their 
centers in the postcentral gyri. Calkins speaks more definitely. 
He holds that the centers for pleasure and pain are in the frontal 
lobes, and that it depends upon the state of nutrition of these 
cells whether the excitation which comes from the motor areas of 

1 At the present time, however, most physiologists hold that the pain center 
is located in the optic thalamus. 


the Rolandic fissure produces pleasure or pain. If the cells are in 
a building-up process, that is, in the stage of anabolism, the result 
is pleasure ; if they are fatigued, the result is pain. If the state 
of nutrition exactly corresponds to the state of need, the result 
will be neither pleasant nor painful, but will be one of indiffer- 
ence. This is a purely speculative hypothesis. What, in the 
first place, produces the nutritive derangement in the frontal 
lobes ? It is a fact that a patient who is fatigued, either mentally 
or physically, will feel painful stimuli more acutely than one who 
is not in such a state of fatigue ; but it is also true that fatigue is 
not necessary to the perception of pain, since even those who are 
in the best of health may suffer from it. 

More recently it has been held that the jDain perceptive cen- 
ters lie in the cortex of the postcentral convolutions, but Thomas 
and Gushing (512) found, during an operation, that the post- 
central convolutions could be manipulated without pain, the pa- 
tient at this time being perfectly sensible and alert to all sensory 
phenomena. The operation consisted of incision of the cerebral 
cortex and removal of a tumor, all without pain. During the 
operation, the patient had not the "least sensation of any descrip- 
tion, though the operative technic required the cutting across and 
the breaking up of many fibers, as well as the irritation of the 
gray matter." It is interesting to observe that these areas cred- 
ited by many with pain production were, when irritated, entirely 
insensitive. This, however, may not entirely negate their pres- 
ence because painful stimuli are effective only in the receptor 
end of the neuron or in the course of the neuron, and it is likely 
that the center of perception, since it possesses no adequate ap- 
paratus to receive a pain stimulus, would be unable to perceive it. 
Centrally projected pains, as from thalamic lesions, are of an- 
other type. Here the associative memory centers lie and at the 
same time it is the region where the third neuron of the sensory 
nerves arises — and thence passes to the periphery. However, if 
centers for pain perceptions are admitted, there must be more than 
one; and at least two must be separated: (a) centers where the 
sensations are received, and from whence they are projected to 



the perceptive centers, as the thalamus, for instance (see tha- 
lamic lesions), and (b) centers which record the painful impres- 
sions in memory, and in the future, either upon some subjective 
or peripheral irritation, project them into the perceptive centers, 
where they give rise, in consciousness, to the sensation called pain. 
The following diagram exemplifies the meaning of this : 

^ ^ SigHT 

T^ECEpTiON Center 






Fig. 3. — Schematic Illustration, Showing How the Various Sensa- 
tions ARE Transmitted from the Periphery to the Brain Cortex 

AND from thence TO THE TwO BrAIN CeNTERS. 

(1) The ideation center where the different, perceptions are correlated into 
thoughts and ideas (objective sensation), and (2) the memory center, 
where the separate perceptions are stored until again they are called into 
consciousness. A block at a would occlude all sensory perception of 
stimuU and the memory storage of the same. A block at b would occlude 
the transmission of present acting sensory stimuh, so that they would not 
be perceived in consciousness. However, the center still receives im- 
pulses from the memory center, which it may evolve into consciousness, 
where they are perceived as acting in the present (subjective sensation). 
If the path to the memory center is destroyed, all recollections of prior 
sensations are lost, and the ideation center, owing to lack of comparison 
with previous sensations, would be unable to correctly interpret the ones 
it then receives and may interpret cold as heat, or touch as pain, etc. 


Memory Centers for Pain. — It is further evident that all of 
the energy received in the areas for painful impressions is not 
transferred to the areas of perception of pain, but that some of 
it is transmitted to the memory areas, from whence, in the future, 
it may be transferred to the areas of mental perception of pain, 
thus giving rise to pain which is subjective in consciousness, and 
therefore called subjective pain. 

In regard to Marshall's second point, it will be showu later 
that special fibers for pain conduction do exist in the peripheral 
nerves, cord, and brain (cortex), and that these fibers carry im- 
pulses from pain receptors existing in special areas, and have the 
single function of carrying pain impulses and no others. Head 
has done more than any other observer to establish the fact that 
the different sensations have separate receptive organs, which re- 
ceive stimuli peculiar to them and to no others. 

Marshall's third objection is harder to meet, in the present 
state of knowledge, for it may be true that certain irritations, 
exerted to excess on some sense organs, may produce pain. While 
as yet no specific pain fibers have been discovered to be present 
in the retina of the eye,^ it is not improbable that such fibers 
exist; or, should they not exist, that the reaction which excess of 
stimulus produces in the receptive optic cells in the brain causes 
fatigue of those cells and that this is transmitted to the fibers of 
adjacent cells, in which a reaction interpreted as painful is pro- 
duced. That such a hypothesis is not entirely without basis, may 
be seen from the assertion that "there are special pain nerves run- 

^In this respect, Foster ("Physiology," 5th edn., Part IV, pp. 281, 
282) agrees with Goldscheider (473, " Ueber den Schmerz, " p. 8), and in 
speaking of the pain from stimulation of the retina says: "We have no evi- 
dence that simple stimulation of the retina, however excessive, will give rise 
to pain, meaning, by pain, the kind of sensation we feel when the skin is cut 
or burnt. We have no evidence that an auditory, or an olfactory, or a 
gustatory sensation can, through mere intensity, become converted into a sen- 
sation of pain. We may assume that the pain which we feel when the finger 
is cut is a wholly different thing from the pain which is given to the most 
delicately musical ear by even the most horrible discord." These considera- 
tions suggest to Foster that cutaneous pain is not simply an exaggeration of 
tactile and temperature sensations, but a separate sensation developed in a 
different way. 


ning parallel to and in the same trunk with the sensory nerves, 
having a special sense of perception in the brain, and operating 
only under the influence of intense irritation." Matzinger's (328, 
p. 138) statement, that "it is unlikely, and contrary to natural 
laws, that there should be an elaborate mechanism of highly or- 
ganized tissue which is destined never to come into use in some 
individuals, or at least only in a very limited way," will have to 
undergo modification, for it has been proven that there are such 
tissues in the form of special nerves (pain, etc.) for certain types 
of sensation (Edinger, Head, Strumpell, etc.). 

As to the fourth objection, that pain must be an attribute of 
sensation because each sensation may be both painful and pleas- 
ant, it is rather difficult to formulate a proper answer. Were it 
not for its clear separation, in the skin, from all other 
sensations, one would be forced almost naturally to the con- 
clusion that pain really is only a qualifying factor in sensation. 
Yet it is possible that the pain sense which one finds in the 
periphery is a highly differentiated touch-sense; that pain is 
present in other organs from a too great stimulation of their 
sensory end organs ; and that pain is present in their centers from 

The fifth and sixth arguments are not supported, in view of 
the general hypothesis that there are specific pain sensations. 

Causative Factors in the Production of Pain. — The produc- 
tion of pain depends upon the presence of a proper stimulus and 
the integrity of the receptive, the conveying, and the interpreting 
apparatus. The stimuli may be divided into those due to me- 
chanical changes in pressure, to toxemia, to chemical changes, and 
to electric or thermic reactions. The stimuli due to Tneclianical 
changes are exerted either upon the terminal filaments of the 
nerve, or on some of the neurons extending from the brain to the 
periphery. This mechanical irritation may- be due to pressure 
from an ijiflartimatory exudate (see Inflammatory Pain), to pres- 
sure hy new growths, or to prolonged, strong contraction of a hol- 
low organ (Mackenzie). Hemorrhage in the body tissues will 
almost invariably cause either deep pressure pain, or epicritic pain 


(Head), unless the rupture is an areolar tissue, when, owing to the 
looseness of the tissues, pain is not present until the local dis- 
tention becomes excessive, or until pressure is made on adjacent 
structures. In regions where the tissues are denser and more com- 
pact, pain is. very severe, even from the beginning of the hemor- 
rhage, as in hemorrhagic pancreatitis. In cavities, also, hemor- 
rhage is often provocative of the most intense distress. This is 
particularly true of the peritoneal cavity. The cause of this ex- 
cessive pain is rather hard to determine, in view of the fact that 
in this location the resistance to the hemorrhage is almost nega- 
tive. It may be that blood possesses some substances which are 
particularly irritating to the peritoneum, and that this irritation 
is transmitted to the body wall as pain. Even as hemorrhage 
causes pain, so also in some cases of congestion, it eases the pain, 
as in swollen turbinates, premenstrual congestion of the 
uterus, etc. 

The extent of the surface stimulated is important in the pro- 
duction of certain kinds of pain. If the area of stimulated sur- 
face is too small, no pain is felt. It seems that, in certain areas, 
only an aggregate of stimuli can produce pain (Tigerstedt, 483, 
p. 467). 

The stimulus which causes pain may not be of any greater 
magnitude than that which is daily experienced by the organism ; 
yet, from frequent repetition, a condition is reached in which, 
before recovery from one stimulus, the cell receives another, and 
so on. Each stimulus leaves a little of its irritative quality, 
until the tension from the accumulation of these irritative 
remnants becomes too great, and release of nervous energy 
takes place in the cell, the pain threshold is reached and the 
sensation of pain results. After once having overcome 
the threshold, secondary discharges take place on a slighter provo- 

Sudden alterations of blood pressure create pain, as is seen 
when a tourniquet, which has been on a limb for several hours, 
is removed. 

Toxemia is a cause of pain, particularly in severe anemia of 


a part, such as is found in emboli of the arteries.^ James re- 
ported a case of complete obstruction in circulation of the aorta, 
in which, after the ligation, the patient had the most severe pain 
(D. W. Mitchell, 263, p. 52). The causes of this, ''Brown- 
Sequard thought to be an accumulation of CO2 in the tissues. 
Vulpian regarded it as being due to the lack of oxygen, while W. 
Mitchell thought that it might be due to sudden annihilation of 
nutrition, osmosis and conditions of pressure." 

Pain may also be due to the accumulation of toxic products 

• Non-compietc v »■ «... 

^ AisimilaTion \ Toxic Products 

V Complete / V..-Non-Complele 

\ Destruction ^ \ Elimination 

.11 \ Increased jcnso.-tj ^ 

Assimilation v \ / — i — t u . . ^ 

Complete \ To«ic Non-completeX Act on the A Produce / '"itabillts 

fe uTfio n' /"°''"-'' Elimination /N^.rje cell W^^^ \ Increased Motor ^ 

uestruction / formed or on ottier Irritability 

Non-complete V / nerve cells through 

Assimilation \ Toxic Products / the means of ttie 

/ Non-compiete V 
ism / Assimilation \ Tox 

lal \ Non-complete/^ 
^ Destrucfion ^ 


This maij accounlfor certain of the pains which we find in hysterical conditions 

Fig. 4. — Diagram showing How Changes in the Cell Metabolism May 
Produce Changes in the Irritability of the Cell and a Depar- 
ture IN ITS Reaction to External Stimuli, Either Making it 
More or Less Sensitive to Peripheral Irritation. 

in a part, as exemplified in the fatigue pains of muscle, wherein 
the products are the result of metabolic waste ; or else the toxin 
may be derived from exogenous sources, as from the alimentary 
tract or from an outside toxic agent, alcohol, etc.. It may also be 
the result of toxins from bacterial organisms. The toxin acts 
upon the receptor cells, or on the sensory nerve substance to 
which the irritant may be transferred. 

As to chemical causative factors,, there may be many, princi- 
pally in burns, severe ischemias, etc. From the nature of the 
condition, toxemias might also be classed among chemical agents, 
inasmuch as in toxemia the poison or irritant is of a chemical 

^ Very severe pain is felt in infarct kidney (Halperin). Pain is also 
extremely severe in arteriosclerotic thrombosis (Buerger and Geis). Intense 
pain is also felt in arteriosclerotic thrombosis of the lower limb, a disease 
which is especially prevalent among the Russian Jews. The pain is so agon- 
izing and constant that the poor sufferers will consent even to the extreme 
remedial measure of amputation rather than bear longer suffering. 


Decreased alkalinity of the hlood, as suggested bj Sir Lauder 
Brunton/ may also produce pain. This may explain the cause 
of the generalized aching pain that is present in infectious 

Photochemical changes in the rods and cones of the retina of 
the eye are produced by light. When the light is too severe, these 
changes are excessive, and the stimulation of the optic nerve 
is stopped or modified, so that vision is obscured and pain results 
(Matzinger, 328, p. 139). 

In some cases trophic changes in the skin may also produce 
pain. This may be peripheral, due to irritation of the sensory 
receptors (protopathic), or central, due to changes in the sensory 
cell distribution in the cord. 

Electrical reactions cause pain, as may be proven by the use 
of the painful, interrupted electrical current (Head, 519). This 
is one v^ay of testing sensitiveness to pain (see Intensity of Pain). 

Heat and cold are frequent causes of pain production, the 
reason evidently being some chemical change in the region of the 
sensory receptors. This, however, will be more fully considered 
in the section devoted to the relation of pain to temperature. 
Freezing of a nerve will cause such an irritability of the nerve, 
below the point frozen, that the least pressure upon it causes pain 
in its distributive area (Weir Mitchell, 263, p. 18). 

Apparatus for Receiving and Conducting Pain. — The various 

forms of receptive apparatus are not, as yet, well defined. Special 

terminal filaments are present for certain forms of stimuli, but 

their distribution is little known. From the universal presence of 

pain, it would seem that the sense-receptive organs for pain are 
^ Sir Lauder Brunton (516) states that he became infected with the 
staphylococcus pyogenes aureus, and that numerous boils developed which had 
a stinging, burning pain, generally worse about three or four hours after 
eating — a time when digestion would be most active, the absorption of the 
acid-formed contents of the stomach greatest, and the alkalinity of the blood, 
from their absorption, least. From this he concluded that the pain was due 
to a decreased alkalinity; and, proceeding on this assumption, he took fairly 
large doses of alkalies, with a resulting diminution of pain. He then tried 
the effect of the bicarbonates, applied directly to the boils, with a consequent 
diminution of pain. In toothache, also, the application of bicarbonate of soda 
to the cavity of the tooth has a beneficial effect. 


widely diffused. These receptors are capable of receiving pain 
stimuli of various kinds, touch, deep pressure, heat, cold. Their 
action may be abrogated by excessive cold, cocain, vibration, elec- 
tricity, etc. These terminal filaments in the skin have been 
called noci-ceptors (nocuous ceptors) by Sherrington (522). He 
classifies as receptors all organs in the skin and mucous mem- 
branes which have developed by a long series of evolutionary 
changes, and which have the ability to distinguish stimuli arising 
from different sources, such as temperature, pressure, or touch. 
Those portions of the body most subject to injury should, there- 
fore, have a more numerous supply of noci-ceptors than those 
portions which are not so exposed. If this is true, we should 
find the fingers, which are exposed to injury, better supplied with 
these ceptors than the brain, which, because of its inclosure in the 
skull, is prevented from injury. Such is the case; for in the 
brain, the cortex is found to be relatively insensitive to many 
stimuli which ordinarily cause pain sensations (Crile and Sher- 

The pain-conducting apparatus consists of the nerve fibers 
leading from the periphery to the sense-perceptive centers. Any 
irritation to the axis cylinders of the sensory nerves in this path- 
way will be transmitted to the periphery and be felt as pain. Irri- 
tation may be in the form of inflammation of the nerve (neuritis), 
of the ganglion (herpes), of the post roots (tabes) within the cord 
(transverse myelitis), or in the thalamus. Various agents may 
act upon the axis cylinder processes (nerves), such as tetanus 
toxins, arsenic, alcohol, etc. The headaches of toxic origin, fa- 
miliar to all, are usually due to stimuli, acting upon the dural 
distribution of the trigeminus. 

Pressure on the conducting fibers causes, as a rule, a severe 
pain reaction. Yet, it is possible for pressure, when equal and 
constant, to be very severe without producing any pain reaction. 
It seems most potent for pain production when it varies in in- 
tensity; the more variable the pressure the greater the severity 
of the pain. Such a pressure we see exerted by new growths, as 
tumors or cysts, or by inflammatory changes, as in meningitis. 


The sense-perceptive centers in the brain may, from oft- 
repeated stimnlation, become hypersensitive. It is often the case 
that, after the original cause has ceased, the hypersensibility re- 
mains, so that stimuli of ordinary intensity, when they reach these 
centers, may be interpreted as painful. Whether this is due 
to a hyperactivity of cortical cells, or to a lowering of the thresh- 
old values in the receptors, has not as yet been definitely estab-' 
lished. The so-called occupation neurosis, in which pain is pres- 
ent when the patient attempts to perform some accustomed task of 
manual dexterity, may serve as an example of this. Here the 
pain, as well as the spasm which accompanies it, may be said to 
represent a rebellion on the part of the overused cortical centers. 
This rebellion does not seem to be so much upon the part of iso- 
lated centers as due to fatigue in the association of certain stimuli, 
which are carried to the affected area from other centers, and which 
have the power of producing certain coordinate actions. The same 
centers may be called into play to make other movements of the 
same muscles without producing pain. Thus, a person who is un- 
able to write without pain may be able to sew without any trouble 
(Walton, 517, p. 261). It should not be overlooked, however, 
that such acts are only apparently similar. In reality they are 
quite diverse. 

We have spoken of the lowering of the threshold to pain. In 
neurasthenia it would appear that, for reasons as yet unknown, 
such a reduction takes place so that the body is more capable of 
reacting to stimuli (including pain) than when it is in a normal 

Shock, anxiety, apprehension, have an effect in lowering the 
pain thresholds for various stimuli. Just what the molecular 
factors may be underlying this change no one knows. Clouston's 
phrase, "disturbance of molecular equilibrium," is as good as any 
other, whatever it may mean. 

Pain and Mental States. — Emotions, like auger and fear, 
sometimes give rise to severe nervous attacks which are typified 
by headaches; and in this relation it is an odd coincidence that 
only the unpleasant emotions give rise to disagreeable sensations, 


for surely no one has ever heard of a pain (headache) being pro- 
duced by joy or happiness. Hypnosis may also have the pow^er of 
bringing into the patient's consciousness an intense perception of 
pain. Some blindfolded persons will experience what they think 
to be pain, if, prior to running a cold instrument across the skin, 
they are told they were going to be cut. In the dream state, also, 
vivid sensations of pain may occur. One of my patients, a non- 
pregnant woman, has been aroused frequently by apparent labor 
pains, of which she had not the slightest perception upon awak- 
ing. The miodus operandi of this perception was described when, 
in speaking of consciousness, the method of transference of im- 
pulses from the receptive center to the perceptive center was il- 
lustrated. There has been some controversy as to whether it is 
possible to imagine pain. The answer seems to be simple; for 
how else would it be possible for the hysteric to draw from mem- 
ory's store, and present to vivid view, sensations which are as 
realistic as though they were actually taking place ? And is not 
imagination, of which the hysteric unconsciously makes abundant 
use, but the power of transferring sensation from the warehouse 
of past experiences to the mart of present change? 

Relation of Pain to Other Sensations.' — We now approach the 
most difficult part of our subject, namely the consideration of 
pain in its relationship to other sensations. Pain is so inextricably 
mixed up with other sensations that at first it would seeni almost 
impossible to unravel the skein. Yet, the riddle is not so difficult 
to solve if we only recognize one factor, and always consider it in 
our study of this subject. This factor is evolution. If we reflect 
that our nervous system is the development of nameless thousands 
of ages ; that from a most simple form it has developed to a most 
complex system; and that during this development its structures 
and functions have constantly been modified by and adjusted to 
the changes in environment, it is easy to understand how, by these 
constant changes and innumerable modifications, it has reached its 
present complex and intricate form. The nervous system at first 
(in our progenitors) was very crude, being litUe more than that 
which was essential for the carrying on of the two great functions 


of the organism, namely, growth and reproduction. As the or- 
ganism developed, it became more and more susceptible to external 
influences, and more and more cognizant of its environment and 
the physical state of its being. At the same time, the means of 
defense were improving, so that the organism was better able to 
protect itself from injury and the external dangers of which it 
was just becoming aware. Probably it was at this time that the 
various external senses were called into activity. An analogue of 
this is seen in the human embryo, in which it is held (Mackenzie, 
69) that the cerebrospinal system is a later development than the 
sympathetic, the sympathetic being concerned with the essential' 
processes of life, while the cerebrospinal is concerned only in 
communicating to consciousness the relationship to surrounding 
objects, the relationship of different portions of the body to each 
other, and the intensity and variety of stimuli which are received 
from different sources. In other words, cogTiition is dependent 
upon this exterior system. So, it is held that the development of 
the cerebrospinal system is for the purpose of defense against 
injury, and that the principal means of communicating the exist- 
ence of such an injury to consciousness is by a series of disagree- 
able stimulations which, by long association, have been grouped 
into various groups and are called j^ain. 

Yet, pain to touch is not the only sensation which, because of 
ancestral necessities, has been developed from the primal sensi- 
bilities of a simple organization. In the same class are tempera- 
ture, light touch, and deep sensibility. Light touch, as it was prob- 
ably the last to develop, is the most vulnerable ; so that, in lesions 
of the peripheral nerves it generally is found to be one of the first 
sensations to disappear. Touch and pain have been regarded by 
some as variations of the same sensation. From the following 
facts, however, these two sensations cannot be considered the same : 

(1) The distribution areas of touch and pain are not identi- 
cal. Were they but modifications of the same sensation, their 
localizations would be exactly similar, and both would be present 
at the same time. The exact opposite of this was present in a 
case reported by Head and Thompson (206, p. 553), where, in a 


lesion of the spinal cord, an area on the limb was insensitive to 
pain, while it was sensitive to light touch and pressure.^ 

(2) Another illustration in point is given by Biernacki 
(Witmer, 527), who states that pain and temperature sense can be 
made to disappear by pressure on the ulnar nerve, while the other 
sensations, as touch, localization, and muscular sense, remain. 
This would argue either for special nerves of pain, or else for the 
reduction in the conductivity of individual fibers; so that if pain, 
in the case of touch, is due to increased molecular vibration, the 
fibers would not be able to carry the stimulus. Yet, such a suppo- 
sition is hardly tenable, from the fact that disease of the cord, 
and of a certain area of it, will produce a loss of pain conduction, 
but not of light touch ; and, vice versa, lesions in the cord may 
produce a disturbance of light touch perception aiid not of pain 

In a case reported by Gowers a unilateral hemorrhage into the 
lateral columns and gray substance of the upper cervical cord pro- 
duced analgesia and thermoanesthesia. In this case there was a 
complete loss of pain on the opposite side of the body, without 
disturbance of light touch. 

From the above it would seem that the pain and temperature 
senses are more closely related than are pain and touch. In 
other conditions the senses of touch and pain appear intimately 
related, as is shown, when by gradually increasing the pres- 
sure on a part, the sensation produced changes from that of touch 
to actual pain. Witmer found that a maximal pressure of 
1.0 gm. or 2.0 gm. will give the sensation of touch greater in- 
tensity. The same stimulus, ranging from 20.0 gm. to 15.0 kgm., 
produces a sensation of pressure, while at times a pressure of 5.0 
kgm. to 15.0 kgm. will give rise both to pressure and pain sensa- 
tions. A maximal stimulus above 15.0 kgm. gives rise to pain 
only. This Head has shown is due to specific receptors of deep 

^ This is frequently found in dissociation imralysis, which is conspicuously 
present in syringomyelia. It is also found, less marked, but much more fre- 
quently than is usually assumed, in neurotic processes, in tabes and in 
paralysis, as well as in alcoholic and hysterical persons. (Osier's "Modern 
Clinical Medicine," "Diseases of the Nervous System," p. 194). 


sensibility whose threshold values are approximately stated by 

In tabetics, also, it is very common for some dissociation be- 
tween pain and touch to be present, as frequently the patient will 
feel the touch of a pin point much sooner (one or two seconds) 
than the pain caused by its penetration into the skin. The term 
delayed pain sensation is given to this state. 

A dissociation between pain and touch sensations may also be 
present under the action of cocain, chloroform, tabes dorsalis, hys- 
teria, hypnotism, etc. During operations, when anesthesia is not 
complete, it is rather common for the patient to complain that he 
feels the touch of the knife, but no pain. Should pain be present 
and touch be absent, the patient will be unable to localize the pain ; 
and, inversely, it is found that the more acute the tactile sense of 
a part is, the more accurate is the localization of pain in that 
part (Hall, p. 442). 

Of the sensations, pain and temperature seem to be the ones 
most closely connected — at least, this holds true in regard to 
the cord, for lesions here more frequently produce a dissociation 
between the other sensations than between pain and proto- 
pathic temperature. That they represent degrees of the same 
sensation cannot be held, because, in the first place, the tempera- 
ture sensation may remain when all the others are absent (Head 
and Kivers, Eef. 86). In such cases, the patient does not respond 
to painful tactile stimuli, but to painful heat or cold stimuli. 
This would apparently show a difference either in the origin of or 
in the conduction of these two sets of stimuli. Yet, pain can be 
produced by a temperature of 36.3° C. to 52.6° C, and cold 
pain by a temperature of + 2.8° C. to — 11.4° C. (Dana, 
529), when the tactile sensibility and the cutaneous pain sensa- 
tion are lost.^ This differentiation of sensation can occur only 

* According to Weber, "the pain produced by heat and cold is very dif- 
ferent from the sensation of heat or that of cold. If the pain is not extreme 
we feel at the same time the heat or cold which causes it, and can then dis- 
tinguish pain due to heat from pain due to cold. But if it is extreme, the 
sensation is the same, whether caused by heat or cold" (Sti-oug, 473). The 
pain sensation is located deeper in the skin than the terminal filaments which 
transmit cold, because, "on contact of a cylinder, slightly heated, with the 


when the superficial nerve is diseased, and deep sensibility 
remains ; for the part of the nerve conveying deep sensibility runs 
with the muscular branch of the superficial nerves, and so may 
escape injury in case of destruction of the cutaneous sensory 
branch. The sensibility to temperature changes is not equally 
distributed, it being greater in some places than in others. That 
heat and cold sensations have separate receptors can be deduced 
from the fact that one may be present in the absence of the other. 
Rivers and Head (86) report a case where the sensation to cold 
was independent of any other sensation. It has been known for 
some time that heat and cold sensations have special areas on the 
skin where they alone, of all the sensations, are present (Gold- 
scheider). Thus it will be seen that, in the course of development, 
certain nerve elements, becoming more highly specialized, have 
arrogated to themselves special functions, one of which is the 
power of being stimulated by hot and cold objects. These recep- 
tors, devised for temperature, are insensitive to electrical and 
mechanical stimuli (Rivers and Head, 86, p. 385). It has also 
been found that stimulation of temperature points or spots by a 
needle will not produce pain (Tigerstedt, 483). Excessive stimu- 
lation by heat or cold may produce only the sensation of pain. 
While it is probable that the correlated senses are present, they 
are not felt because of the overwhelming of the consciousness by 
the intensity of pain sensation. Hyperalgesia to temperature 
may be present without hyperalgesia to touch (Stern, "Archiv fur 
Psychiatric," 1886) ; and it has also been noted that hyperal- 
gesia for heat may not be as marked as it is for cold. 

Conveying Channels for Sensations.— It is apparent that while 

skin, on which a blister had been applied and the epidermis removed, a painful 
stimulus ■without a trace of heat sensation was felt" (Mettler, 505). 

A case in point is reported by Barker, wherein, because of pressure of a 
cervical rib, certain conditions occurred in the area of distribution of the 
nervi cutanei brachii et antebrachii mediales of the, left arm. He found that 
in some areas careful testing showed that pricks with a fine needle gave only 
pain, without calling forth previous touch or pressure symptoms. Ice at first 
gave no sensation, then pain. Heat gave rise only to heat pain, without pre- 
vious heat sensation. A stimulus of 47° C. (116.6° F.) and upward quickly 
caused pain, but no sensation of warmth. Barker claims that the pain was 
due to stimulation of pain organs. (Witmer, 527.) 


the sensations of touch, temperature, pain, and deep pressure pain 
are closely related, thej are separate entities, and that each is 
carried bj its own specially differentiated and functionating 
nerves.^ We have already referred to these, hut will discuss 
them again more at length. 

^ There has always been considerable discussion among physiologists as 
to the presence of pain nerves and pain tracts. Advocating the existence of 
pain nerves are Strong (533), Krehl (534), Von Frey, Piersol (537), Nichols, 
Bianchi ("Psychiatry," p. 358), Funke, Head, Goldscheider, etc. Opposing 
the idea are Hall, Marshall, Mantegazza (536), Dana, Brown-Sequard, Mun- 
sterberg, James, Ziehen and Weir Mitchell (263, p. 40), who says: 

"Do you suppose that there always exist in these organs pain nerves, and 
that only once, perhaps, in a lifetime, these filaments are to be roused into activ- 
ity?" He further says: -"As regards the skin, how shall we deal with the like 
difficulty if we choose to believe that everywhere are peculiar nerve fibers de- 
voted only to transmitting painful sensations?" So he concludes that pain is 
not a ' ' distinct sense, with afferent tracks peculiar to itself, ' ' but that it is 
' ' the central expression of a certain grade of irritation in any centripetal 
nerve." He goes on to say (p. 48) that if a nerve is cut, and "the nerve ends, 
having been allowed to cicatrize without union, should be constantly irritated 
by imprisonment in the hard tissue of stumps or scars, or by a neuritis, a great 
variety of peculiar sensations are felt, such as the feeling of being tickled, of 
motion in the lost or disconnected part, heat, cold, etc. These facts seem to 
prove that some peculiar peripheral arrangement for the production of touch, 
sense of movement, and the like, is without firm physiological foundation. ' ' 

The last example is hardly to the point; yet, at the time of writing, it 
was well taken. To-day it is recognized that, upon irritation of a nerve, the 
pain is referred to the peripheral distribution of that nerve because the brain 
cells have learned to interpret such a stimulus as coming from a particular 
area, and will so continue to interpret it when the direct communication with 
that area is interrupted; so that irritation applied in the course of a nerve 
is always felt as though it were coming from the peripheral distribution. 

One of the strongest advocates of special nerves of pain is von Frey, who 
gives the following reasons for his belief: 

(1) "By observing certain precautions, mechanical stimulation of the 
skin with a bristle produces a pure sensation of pain, without any prelimi- 
nary or accompanying sensation of pressure. 

(2) "If a bristle be placed over a pressure point, the sensation appears 
immediately, but at once fades away again, and usually becomes unnoticeable 
after a short time. Over the pain point, the effect appears later, gradually 
increases in strength, and decreases again after reaching a maximum. 

(3) "When the head of a pin is pressed for a moment into the skin there 
follows very often, after the sensation of pressure, and separated from it by 
an appreciable interval, the sensation of pain." 

Von Frey claims that on the back of the hand, over the metacarpus of 
the ring finger, sixteen pain points can be demonstrated as against two 
pressure points. The nerve endings which convey pain are, he believes, prob- 
ably the free intraepithelia nerve endings (Tigerstedt 's "Physiology," p. 467). 


The channels for conveying sensibility are divided into super- 
ficial and deep sets (Head and Thompson, 206). The superficial 
set is again divided into two others, the protopathic ^ and the epi- 
critic. These differ from each other principally in their power of 
conveying degrees of stimuli, the epicritic being finer, and capable 
of conveying slighter degrees of stimuli. It is probably a later 
evolutionary development than the other. Pitt (530) states that 
it is developed after birth. According to Head, Rivers, and 
Sherren (85), Head and Sherren (86), and Head and Thompson 
(206), the systems for conveying sensations, with the stimuli 
which they carry, are as follows: 


System of System of System of 

Deep Sensibility Peotopatiiic Epicritic 

Sensibility Sensibility 

Deep pressure, which, Painful cutaneous Light touch. 

when excessive, is stimulations. Character of touch. 

interpreted as pain. Extremes of heat and Js^umber of points of 

Localization of pres- cold (below 20° C. pressure. 

sure. and above 45° C). Distance points are 

Alterations in the Visceral sensation. apart. 

positions of the Painful sensation Character of surface 

joints, muscles and from a prick. touched. 

tendons. Electrical stimula- Slight differences in 

tion. temperature. 

Wiindt (Strong, 437) assumes that in the peripheral nerves the paths of 
pain impulses are the same as those of touch, heat and cold impulses. When 
tactile or temperature impulses reach the cord they find two paths open: a 
primary path, leading through the white matter, and a secondary path, or 
paths, leading through the gray matter. Impulses of moderate intensity take 
the primary path, and this path can accommodate only moderate impulses. 
When excessive impulses come, they overflow into the secondary paths and 
pass upward through the gray matter. Tunke and Goldscheider ("tJber den 
Schmerz, " p. 19) agree with the assumption that each nerve carries two sets 
of impulses, one giving rise to the ordinary correlated sensations, and the other 
producing pain. 

The very full discussions of Head and Holmes {Lancet, January, 1912) 
give the latest summary of these studies. 

1 Goldscheider (62b) holds that the protopathic system does not exist, and 
that the so-called protopathic sensibility is but an expression of the lessened 
functional power of the nerve apparatus. 


According to Head and Rivers, the fibers conveying deep sensi- 
bility accompany the muscular branches of the nerves, and are 
distributed, in many cases, to the deeper tissues and the tendons 
of the muscles. This is in accordance with the anatomical find- 
ings of Sherrington (205, pp. 255-256), who says that "macro- 
scopic nerve trunks are not purely motor, but are sensorimotor 
or purely sensory. Such nerves as the phrenic, hypoglossal, re- 
current laryngeal, and posterior interosseous contain an abundance 
of fibers from sensory ganglia." In muscles, the special end 
organ for root ganglia fibers is called a muscle spindle (Kuhne-). 

The nerve fibers conveying these different sensibilities do not 
all converge into the same nerve or roots, although the fibers con- 
veying the same sensation from the same part of the skin do so, as 
a rule. For instance, the protopathic fibers from the same area 
converge and are all found in the same posterior roots. As a con- 
sequence, in root injury (diagnostic point for root injury) they 
do not overlap, while the ej)icritic fibers do, being conveyed, prob- 
ably, by several roots and first being merged in the cord. 


% Deep, epicrjtic and pro- 
topathic sensation. 

Epicrltic and 
protopathic sensi- 

Fig. 5. — ^Aeeas of Epiceitic and Pegtopathic Sensibility. 

In the accompanying drawing is seen the effect of injury of 
the sacral plexus below the point where it is joined by the second 
sacral nerve. The third sacral nerve had been destroyed, and the 
nerves were bound up in a dense mass of fibrous tissue (Head 
and Thompson, p. 552). This illustrates the effect of injury to 
the peripheral nervous system before the fibers have been joined 
into separate conduction paths in the cord. These conduction 
paths for pain, muscle sensibility, touch, and pressure are separate 
and distinct. This is illustrated in Fig. 6, taken from Head and 



Thompson, which shows the effect of injury to the pain-conduc- 
tion paths in the c^rd. 

The painful impulses from the skin enter the cord by way of 
the protopathic system. They probably become combined at once, 

Fig. 6. — Effect of Injury to 
THE Pain-conduction Paths 
IN THE Cord. 

In the shaded area the parts 
were insensitive to all painful 
stimuU, while at the same time 
they were sensitive to light 
touch and pressure. (From 
Head and Thompson, 206.) 

Fig. 7. — Unilateral Complete Lesion 
ON One Side of the Cord Produc- 
ing A Narrow Band of Anesthesia 
ON the Same Side at the Level of 
THE Lesion and a Broader Zone op 
Anesthesia on the Opposite Side 
Slightly Below the Level op the 
Lesion. (From Edinger, Nervosen Zen- 
tralorgane,6 Auflage, p. 377, Fig. 263.) 

and enter the intramedullary system at the level of their entrance. 
The fibers from the deep system do not enter by the same posterior 
roots as those conveying painful cutaneous stimuli. Thus, more 
than one segment of the cord is required before all the painful 
impulses from any one part of the body can be gathered together 
and recombined. After being recombined, they pass across the 
commissure to the opposite side, where they .ascend in the tractus 
spinothalamicus et tectalis. The decussation takes place in the 
course of four or five spinal segments (Piltz, 407). According 
to Camp, it may take six to eight. This peculiarity of structure 
accounts for the irregular distribution of pain sensation in uni- 



lateral lesions of the spinal cord. If the lesion is not extensive 
enough to involve all the fibers coming from a part, there may 
be a very indefinite loss of sensation ; but if the lesion is extensive, 
there is a definite loss of sensation in an area above and an in- 
definite loss below the lesion, while on the opposite side of the 
body the sensations are entirely abolished below the level of 
the lesion. Fig. 7, from Edinger, shows nicely the sensory results 
following a unilateral lesion of the cord. 

In the accompanying drawing an effort is made to illustrate 
the course of the sensory fibers. The fibers for all the sensations 
enter the posterior root separately, and pass from thence to the 
cord. In the ganglion, these fibers come into relationship with 
the ganglion cells, with which they are connected, some of the 

Anterior or motor root. 

Posterior ganglion cell. 

Fig. 8. — Cross Section of the Spinal Cord, 
This represents on the left side the views of Dogiel and Snuf on the course 
of the sensory fibers in the posterior root; while on the right side is illus- 
trated the view of Donaldson in regard to the division of the sensory 

ganglion cells being connected with more than one afferent fiber 
(Head and Thompson, 306). It is in these ganglion cells that 
the afferent fibers from the viscera have their origin. According 
to Warrington and Griffith (414), not more than two per cent, of 
all the cells in the spinal ganglion are connected with the viscera. 
This accords with Langley's statement that the total number of 


sensory fibers distributed to the viscera about equals the number 
of sensory fibers present in a posterior root. Dogiel and Onuf 
found the axis-cylinder processes of certain cells of sympathetic 
ganglia terminating around cells of a spinal type. 

Ludlum suggests that the visceral nerves may give off col- 
laterals in the spinal ganglia, and that these, coming in contact 
with a spinal neuron, may transmit the stimulus to it. This 
stimulus would then be perceived as coming from the peripheral 
distribution of the neuron, in the distribution area of vvhich the 
pain would be perceived. On the other hand, Donaldson be- 
lieves that the peripheral branch of a spinal ganglion nerve splits, 
and that one of the branches is carried to the somatic distribution, 
while the other, through the ramus communicans, is distributed 
to the viscera. In this case, any irritation of the viscera would 
so alter the ganglion cell that, if the irritation were strong 
enough, it might give rise to pain; or if it were not severe 
enough to cause pain, it might produce such an alteration in 
the cell that a state of hypersensibility would ensue, and the 
slight irritation in its peripheral distribution would then be per- 
ceived as pain. 

After the entrance of the sensory fibers into the cord, they 
are joined into well-defined bundles, all the fibers of a single 
bundle having the same function. The fibers entering the poste- 
rior cornua may be defined as follows (May, 397, p. 759) : 

(1) Fibers which enter the post-columns, and then divide 

into ascending and descending branches from each of 
these collaterals, pass at various levels of the cord and 
end in gray matter (Schultz Col., 430). 

(2) Fibers which pass forward and end around the cells of 

the anterior horn (Edinger, 421). 

(3) Fibers passing to Clark's column (Edinger, 421). 

(4) Fibers which go to the cells of the posterior horn, lat- 

eral column, then end in the gray matter of the poste- 
rior column of the same side, but do not cross (Rus- 
sell, 428, Mott, 429). These fibers terminate in the 


medulla (post-column nuclei), but during "their 
course collaterals and some main fibers terminate in 
gray matter" (397). 
(5) Fibers which pass to the post-column. Collaterals are 
given off and pass to cells of the gray matter, and end 
generally around cells of posterior horns. The fibers 
themselves terminate around cells in the posterior col- 
umns, and some extend as far as the columns of Goll 
and Burdach in the medulla (397, p. 760). 

Fibers arising in cells of gray matter are : 

(1) Fibers running in antero-lateral columns, same side. 

(2) Fibers running in post-columns, same side. 

(3) Fibers branching, one part running in the antero-lateral 

column of same side, and the other branch passing over 
in anterior commissure to run in antero-lateral column 
of opposite side. 

The above are primary paths. Secondary paths are also pres- 
ent in the cord. They are represented by : 

(1) Fibers which arise in Clark's column of the same side, 

and run to the dorso-spino cerebellar tract (path of 
Flick and Foville) lying exterior to the crossed pyram- 
idal tract, and anterior to the post-root fibers. "In 
the medulla they are joined by a bundle of fibers from 
the crossed inferior olive, and pass directly into the 
restiform body, and thence to the cerebellum" (397, 
p. 763). 

(2) The ventro-cerebellar tract forming part of Gower's 

tract, in which the fibers arise: (a) In the cells of the 
posterior horn and intermediate gray substance of the 
opposite side, (b) In the cells of the posterior col- 
umn of the same side. Both pass up in the cord and 
brain, and terminate in the cerebellum. 

A — Restlform 

B — Transference 
pain felt on both 

C — Transference 
pain felt on op- 
posite side. 

D — Pain felt on 
same side. 

E — Motor reflex 
same side as pain. 

F — Touch and 

G — Transference 

I — ^Temperature. 

Fig. 9. — Diagram Showing Intraspinal Course of Sensory Fibers. 


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(3) The fibers of the tractus spino-thalamicus which arise 
in cells in the posterior horns, cross over in anterior 
commissure to the spino-thalamicus tract, and pass 
upward to end in the thalamus. Collaterals are sent 

(a) The lateral fillet of the same side. 

(b) The post-corpora quadrigemina of the same side 

and the opposite side. 

(c) The anterior corpora quadrigemina of both sides. 

The ascending path in the anterior column consists of: 

(1) Long and short intersegmentary fibers, the exact origin 

and terminations of which are obscure. 

(2) One set of fibers which arises from the lateral bundle, 

passes into the anterior columns, and thence up the 
cord to terminate in the inferior olive (May, 397, 
Dydjnski, Bechterew). 

rigures 9 and 10 will give a diagrammatic idea of the course 
of these fibers. 

After passing through the mesial fillet the fibers enter the 
thalamus (May, 397, pp. 789-791), from whence they are dis- 
tributed to the cortex, some, at least, posterior to the central fissure 
of Rolando (397). 



The sensation of pain is either deep-seated or superficial. 
When deep-seated, it is carried, as a rule, by the nerves of deep 
sensibility from the tendon receptors. These are termed the ten- 
don spindles (tendon organs) of Golgi (Howell, 539). They do 
not degenerate after section of the anterior roots, and therefore 
must be derived from the posterior roots and are sensory in origin 
(Sherrington, 540). They are particularly irritated by anything 
which disturbs the relationship of the subcutaneous structures, 
such as deep pressure, or the rolling of the tissues over each other. 
Pressure made on the skin, raised in a fold, the base being held 
tightly between the fingers, will not be felt. This shows that 
this type of sensation (pressure sense) resides in the deeper struc- 
tures, the muscles and tendons (Striimpell). 

Superficial pain (protopathic system) is carried by the cutane- 
ous nerves. Here the pain fibers are associated with those carry- 
ing sensations of heat, cold, and light touch. These sensations are 
all separately received upon special nerve receptors, found in 
the skin in well-defined minute areas, each area being associated 
with a particular specific sensation. That the nerve fibers for 
temperature and pain are closely associated in the same nerve 
bundle is seen from the fact that, if either of them is irritated, 
the pain, if referred to a distant area, is felt in the same area 
(Kivers and Head, 86, p. 417). These local areas of sensibility, 
in which the pain fibers originate, ''vary greatly in activity and 
threshold." According to von Prey, the pain points are those 
pain spots of lowest threshold in any particular area of the skin. 
Landois (541) states that the pain points do not coincide with 


the pressure points which are present on the same area, but are 
about one thousand times more numerous. 

The epicritic differs from the protopathic system, in that it 
does not transmit pain, but seems to be concerned with the dis- 
crimination of the finer variations of sensation. It is the last 
sensory system to appear, being developed after birth. Following 
an injury to a cutaneous nerve, epicritic sensibility does not return 
until some time after the recovery of the other types of sensibility. 
For instance, pain returns before the sensations of light touch, 
warmth, coolness and the discrimination of two points of a com- 
pass. According to Head and Sherren (295, p. 163), the time 
necessary for the return of sensibility in the following systems 
after section of a cutaneous nerve is as follows : 

Peotopathic Epickitic 

Begun Completed Begun Completed 
Ulnar, with dorsal 

branch intact ? days 133 days 183 days 320 days 

Complete ulnar nerve. 109 days lYl days 169 days 278 days 

Median nerve 65 days 190 days 262 days 387 days 

Median and ulnar 

nerves 101 days 217 days 271 days 470 days 

A peculiarity of pain sensibility is that, in the absence of ther- 
mal sensibility, a temperature between 40° and 44° C. will cause 
pain ; but as soon as the thermal sense returns it requires a higher 
degree of stimulation to overcome • the inhibition of the convey- 
ance of the pain stimulus by the conducting apparatus normally 
resident in the part. The protopathic nervous system gives rise 
to hyperalgesia, but the areas of hyperalgesia derived from dif- 
ferent nerves so overlap that they are useless as a means of 
defining the distribution of any peripheral -nerve. On the other 
hand, the epicritic nervous system gives well-marked, delimited 
areas which may be used to define sensory nerve-distribution areas. 
This means of discrimination can only be used when the lesion 
is in the course of a nerve. When it is in the nerve root, the 


regions of distribution greatly overlap (Tigerstedt and Sher- 
rington), so that the '^lateral aspect of the body is provided with 
a twofold, or even a threefold nerve supply." 

Pain Localization. — To localize pain, it is necessary that the 
sense of touch remain intact. When it is diminished, there is a 
tendency for the sensorium to refer the pain sensation to a part 
where the touch sensation is more acute. An aid which the patient 
instinctively uses, in his attempt to localize sensation, is motion. 
Let the sense of touch in a finger be dulled, for instance. One 
may then prick the finger, and the patient will not be able to tell 
from where the pain comes ; but grant him the privilege of mov- 
ing the finger, ever so little, and the touch upon his finger, and the 
pressure against it of the pricking object, will enable him correctly 
to localize the site of the irritation. This localization is explained 
in the work of Head and Sherrington (263, p. 185), who find that 
the muscles have a slightly different sensation from the skin, 
and also that the muscles are not supplied by the same nerve 
fibers which supply the skin, so that, by means of this involved 
muscular supply, a correct localization can be made. When a 
lesion is on the nerve circuit, a correct localization of the in- 
jury is made by means of the nervi nervorum, as in a case re- 
ported by Mitchell (263, p. 193), wherein "a blow had fallen 
on the ulnar nerve at the elbow. The pain was felt in the 
fingers, but there was also a well-defined sense of hurt at the point 

However, every portion of the body is not equally supplied 
with pain filaments. The abdomen seems to be most liberally 
supplied, then the chest, extremities, neck and back (Crile, 521). 
The structure which is probably the most sensitive to pain is 
the conjunctiva of the eye. 

When the patient himself subjectively localizes a pain, one 
should always insist upon his being definite in his statements, and, 
if possible, have him indicate with his hand the area affected. In 
some cases, the pain occupies an extensive, but rather indefinite, 
area, so that the patient is unable to delimit it exactly. In these 
cases (Schmidt) the focus is generally at the point where the pain 




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first occurred (inflammatory pain). This is true only of local 
pains ; other varieties will be described later in the text. 

According to Tigerstedt, Pryer and Krause have asserted that 
the skin covering any given muscle is supplied with sensation by 
the same spinal nerve which supplies the muscle.^ This was also 
a dictum of Hilton; but it has been shown to be untrue by Sher- 
rington. He found that, during development, certain displace- 
ments occur, causing the skin regions to be situated somewhat 
more distally than the muscles with which they are related through 
a common nerve supply. 

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POST. Tibial 

Cutaneous Distribution of 

Peripheral Nerves. (After 

The sensory nerves of a muscle jDrobably belong to the same 
cord segment as the motor nerves of the same muscle. 

In the "peripheral distribution of the sensory fibers, four dif- 
ferent areas must be defined, namely: 

^ Tigerstedt gives the flexor surface of the thigh and foreleg and the an- 
terior side of the arm as the only exceptions to this rule. 



(1) The areas of distribution of the peripheral nerves. 

(2) The areas of distribution of the different plexuses. 

(3) The areas of distribution of the posterior roots and their 

corresponding segments. 

(4) The areas of distribution of certain areas related to 

visceral disease, as defined bj Head and his associates. 

Fig. 13. 

Fig. 14. 

Figs. 13 and 14. — Cutaneous Nerve Supply, Showing the Distribution 
Areas of the Different Plexuses. (Toldt, Part VI, p. 811.) 

The area of distribution of the sensory fibers in the peripheral 
nerves, because of their overlapping, is rather difiicult to outline. 
This accounts for the great variation in boundaries, as given by 
the leading vt^orkers in this field. Figures 13-17 are a composite 
of the description and the drawings (see figures) of the principal 
authors consulted. 

Any lesion causing irritation in the course of a peripheral sen- 
sory (pain) nerve would cause the pain to be referred to the dis- 
tribution area of this nerve. Care must be taken, however, not to 
allow the overlapping of the distribution areas to render the de- 
ductions misleading. 

The distribution areas of the sensory fibers in the posterior 
roots and in the corresponding segments of the cord, as given by 













Fig. 16. — Distribution of the Nerves Derived from the Sacral 





different authors, differ even more widely than do those of the 
peripheral nerves. The distribution, as given by Thorburn, Starr, 
and Kocher, is shown in Figures 18-23. Figure 23 shows the 
relationship between the cord segments and the different nerves. 


Inteq.Chest ^- 
(S Abdomen ^V^^ 


- i _ ' ^•^Lonqissimus 
1 -^ Dors I 


Fig. 17. — Dorsal Nerves. 

There are also on the body surface certain well-defined zones 
which are related to visceral diseases ; they were first described 
by Head, who, while working in the London Hospital, noticed 
that, in different diseases of the viscera, areas or zones of cu- 
taneous hyperalgesia were found which coincided rather closely 
with the areas of distribution of herpes of the different regions. 
Since herpes was due to a disease of the posterior root ganglion 
(Head and Rivers; Church, 542, etc.), he concluded that in the 
ganglion certain stimuli must be transmitted from the visceral 
fibers to those going to the somatic areas, and produce an in'ita- 














1 5.J 

[ S2 


Fig. 18. — Cord Zones According to Kocher. 
These represent the cutaneous areas mvolved in lesions of different segments 
of the cord. The circles represent the areas of maximum tenderness 
according to Head. Head's zones and these do not entirely coincide 
because Head worked out his zones from a study of \'isceral lesions and 
somewhat arbitrarily defined them, while Kocher used the peripheral 
disturbances occurring in lesions of the cord as the means of defining his 
segments. These really represent the distribution areas of the posterior 


Supraclavicular, 3, 4, C, 

Circumflex, 5, 6, 7, 8, C. 

Nerve of Wrisberg, 1, D. 

External cutaneous. 
Internal cutaneous, 8, C, 1, D. 

Musculocutaneous, 5, 6, 7, C. 
Iliohypogastric, 1. L. 

Ilioinguinal, 1, L. 

Genitocrural, 1, 2, L. 

Median, 6, 7, 8, C, 1, D. 

External cutaneous, 2, 3, L. 

Middle cutaneous, 2, 3, 4, L. 
Internal cutaneous, 2, 3, 4, L. 

Plexus patellae. 
Internal saphenous, 2, 3, 4, Ii. 

Branches from external pop- 
liteal, 4, 5. L, 1, 2, 3, 4, S. 

Musculocutaneous, 4, 5, L. 1. 

2, 3, 4, S. 
External saphenous, 4, 5. L. 

1, 2, 3, 4. S. 

Fig. 19. — Cutaneous Areas Related to Spinal Cord Segments (Church and 
Peterson, p. 56, after Starr) and Cutaneous Distribution of Nerves 
(Church and Peterson, p. 52, after Fowler). 



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.__ Jf. to reetut lateraUs 

I —to recttia antic, minor 

—Anaatomosia with hi/poalosaal 

>~^—— Anastomose^ wtth pneumogastric 

i*^. to rectus antic,major. 

2f. to maatoid region. 

Oreat auricular n. 

' Transverse cervical n. 

F^^\N. to Trapezius, Ang. Scap. and Bhomboid. 

. Supraclavicular n, 

^ Supra^cromiat n. 


N. to levator ang. scap. 

JV. to rfutmboid 

——Sub^apular tu 

!f. topettoraltt major 

Cireu7i\flaB n. 

ilu3cuto<tilantous n,. 

Median n. 

Radial n. 


Internal cutaneous n. 
I— ——^^—_ -£maU internal cutaneous A. 

,t..IHa*vpoaa^r{e n. 
..Itio-tngulnal n. 

..External cutaneous i. 
.OenftocT-urof n. 

.Anterior cniml n^ 
___06tura/or r. 

K. ioJevatorani. -^^^Nt 

J^. »o oftfurofor int ^y^A 

y. to ophincter anf. 

Coccyfeal n, 


__.Suj>erior gluteal n. 

_. tf. to puriform it 

If. to gemellus super. 

iV. to genetli/s infer 

.Jf. to guadratus 

.Small sciatic n. 

.S-jiattc n. 

Fig. 23. — Relationship of the Segments of the Spinal Cord Ai>n) 

Their Nerve Roots to the Bodies and Spines of the Vertebra. 

This is the reason for the location of the distribution segments lower than one 

would naturally expect. (Keen's System, Vol. II, p. 843.) 


Fig. 24. — Cord Zones Fig. 25. — Cord Zones and Areas Fig. 26. — Cord Zones 
AND Areas of Max- of Maximum Tenderness Ac- and Areas of Max- 
imum Tenderness cording to Head. imum Tenderness 
According TO Head. According to Head. 



tion of these fibers, so that lighter than ordinary stimuli give rise 
to pain. These areas are given in Figs. 24-26. At the present 
time, they are acknowledged, in the main, as correct; and while 
many have slightly modified the areas, the modifications are so 
slight and so varied that it has been thought better to reproduce 
the original drawings of Head. 



There are two states of perception, or rather, degrees of inter- 
pretation, of pain-sensation, namely: (1) The condition or state 
in which sensation is almost or entirely absent, anesthesia (when 
the sensibility to pain alone is absent, it is called analgesia) , and 
(2) the state in which sensation is more acute than normal, and 
in which the slightest irritation will produce a more pronounced 
reaction, or hyperesthesia (if the pain reaction alone is increased, 
it is called hyperalgesia). Intermediate between these two is a 
class of conditions producing symptoms not severe enough to be 
classed as hyperesthesia ^ but which, because of their peculiarity, 
cannot be classed as normal. These are the paresthesias, in which 
creeping sensations, etc., are present over a part. 

Analgesia. — Analgesia may be either central or peripheral. 
When central, the lesion may be in the brain, or spinal cord. 
When it is in the brain, it may be either endogenous or exogenous. 
Endogenous analgesia is present during severe emotion, such as 
great joy, anger, and fear, as is seen in the disappearance of a 
coothache as soon as the patient enters the dentist's office, or the 
cessation of pain when the patient is in mortal terror. It may 
be present during arduous mental work which requires great con- 
centration of thought, and also in states of mental exaltation, 
such as exhibited by religious zealots, examples of which are the 
Buddhist fakirs. In such cases, a perversion of sensation, from 
strong religious excitement, seems to have taken place, so that, 
while undergoing the most severe tortures, no pain is felt. In- 
stead even a sensation of pleasure is experienced. Just what 
factors underlie this type of phenomena is far from being satis- 



factorily explained. Some have assumed states of localized 
anemia or hyperemia consequent upon variations in blood pres- 
sure. Others assume changes in the resistance to the passage of 
nervous energy in completing nerve paths. Others assume a 
"spill" hypothesis, namely, that emotional excitement lowers the 
tension in certain nerve paths, and thus drains off the sensory im- 
pulses, so that the nerve is not able to properly conduct the stimu- 
lus, and radiation takes place into the adjacent tissues. Again, 
others assume blocking processes which shut the sensory percep- 
tions out of consciousness. Thought along these lines is in a, 
state of flux. JSTothing is definitely known. 

Toxic Analgesia. — Certain forms of toxemia are powerful 
in retarding the perception of pain. They produce a dulling of 
consciousness, varying all the way from cloudiness of intellect 
to unconsciousness. Such toxemias are found in many states 
and diseased conditions of the body, as acute infectious diseases, 
the terminal stages of malig-nant processes, uremia, acute yellow 
atrophy of the liver, etc. They are also present in cases of failing 
circulation, such as occur prior to death, in fainting, and after 
severe hemorrhage. This is hardly the place to speak of the 
mentally defective, who, because of retarded development of the 
perceptive faculties, are backward in their ability to experience 
pain. These states are found in idiocy. In jDsychoses of various 
types, also, the pain-perceptive centers are dulled. 

VoLUNTAEY Analgesia.-^Iu some cases, there seems to be 
an ability to inhibit pain-jDerception, as is seen in a case reported 
by Witmer, of a "professional painless man." In this case, pins 
and needles could be pushed into the skin ; also, he could hold a 
red-hot half-dollar in his hand without wincing, until it had 
burned itself deep into the flesh. Witmer, from a consideration 
of the circumstances of the case, believed that the subject inhibited 
the sensation of pain, and not its external manifestations ; that 
is, that he did not perceive the pain, and was not stoically en- 
during it. The patient was possibly a syringomyelic. Many of 
us, by sufiicient training, are aUe to inhibit the sensation of pain. 
According to Mitchell, some women remain for years without the 


peripheral pain sense, tliough the general health is unimpaired, 
while the internal organs are still sensitive to pain, and all forms 
of skin sense are as keen as ever. 

The extrinsic or exogenous causes acting to produce analgesia 
are all those conditions which produce a lowered pain perception. 
Chief among these are drugs, morphin and ether probably taking 
the highest place among them. Both act by obtunding conscious- 
ness, although either may cause analgesia before consciousness 
has entirely disappeared. 

Anesthesia. — It is often a subject of controversy whether or 
not a patient feels pain while under an anesthetic. It seems 
foolish that such a controversy should arise, when we know that 
pain is a concept of the higher sensorium, and that as soon as 
consciousness is dulled the sensorium becomes inactive, and the 
body is unable to perceive pain, although it may be able to per- 
ceive touch. To illustrate this, I will recount a little personal 
experience of several years ago. After using ethyl chloride suc- 
cessfully upon a patient. Dr. Henry Hall suggested that I try 
some. This I did, and after a few seconds the surroundings 
seemed to become distant, and, while I could see and hear, I 
was unable to move. When the doctor touched me and asked 
me to tell him when he did so, I was unable to intimate by word 
or gesture that I did not feel him, although I could see him 
touching me. 

Anesthesia is in reality an inhibition of perception. The physi- 
ologists are agreed that the first phenomenon which is abolished 
during anesthesia is that of voluntary movement, after which come 
the loss of spinal reflexes, loss of pain, and finally loss of con- 
sciousness. It is also agreed that loss of pain-perception precedes, 
by a noticeable interval, loss of consciousness. Crile is not in 
accord with this, for he believes that the only result of an anes- 
thetic (ether) is obtunded consciousness. The disturbing stimuli 
from the irritated area are carried to the brain, just as though 
the patient were conscious, and exert the same irritative action. 
The only difference is that the patient is not aware of their 



Interference ■with tlie areas of pain-perception will also cause 
a loss of pain-perception. This is seen esj^eciallv in all those cases 
in which pressure is made upon the pain-centers, as in tumors, 
hemorrhage, or pressure from a depressed fracture of the skull. A 
case of this kind was reported by Leszynsky (550), in which, 

after a fracture of the 
skull, there developed, 
along with motor symp- 
toms, an anesthesia ex- 
tending around one leg. 
It resembled an hysterical 
anesthesia in that its boun- 
daries were transverse, 
and did not in the least 
resemble the boundaries of 
the areas of distribution of 
either the peripheral sen- 
sory nerves, the posterior 
roots, or the cord seg- 
mental zones (Fig. 27). 
In this case, ''there was 
an area of complete anes- 
thesia, extending from the 
toes to about two and a 
Fig. 27.-AREAS of Anesthesia ox Leg ^^^i inches below the pa- 
DuE TO Depressed Feacture of 

gg-^-LL. ^^^^^ anteriorly, and to 

o. Thermoanesthesia; b. tactile and thermo- about three inches below 
anesthesia; c. complete anesthesia. , t ^ 

the popliteal space poste- 
riorly, with a circular band of dissociated sensory disturbance 
above this. For two inches above the level of the complete anes- 
thesia, the tactile and temperature sensibility were abolished and 
the pain-sense was preserved. For one inch and a half farther up. 
thermoanesthesia persisted without impairment of other forms 
of sensibility. The patient stated that about one week be- 
fore entering the hospital he noticed beginning loss of sensi- 
bility in the leg, and that about two weeks later the loss was 


complete. The loss of sensibility to the application of the f aradic 
wire brush extended from the toes to about three inches below 
the level of the area of complete' anesthesia. The senses of po- 
sition and of localization were normal in the toes and foot. The 
senses of localization and of pressure were absent in the leg. 
The upper extremities and the other lower extremity were nor- 
mal. There was no astereognosis. The visual fields as measured 
with the perimeter were practically normal." This case brings 
the point prominently to the mind that there are areas in the 
cerebral cortex which are connected with the sensory distribu- 
tion of different regions of the body. This is important in the 
etiology of hysteria. 

Paresis frequently gives rise to anesthesia, which, according to 
Clouston, is due to loss of inhibition ( ?) in the cortical areas. 
It would seem more likely, from the pathology of this condition, 
to be a loss of perception in the cortical areas. 

Passage of an electric current of 1,000 volts through the body 
will cause anesthesia, probably due to encephalitis causing 
inability of centric perception (Hoover, 554). 

The peripheral causes of anesthesia are all those conditions 
arising in the nerve pathways which act as obstructions to the on- 
ward progress of the pain stimulus, chief of which, of course, is 
severance of the pathways by section of the nerves or spinal cord. 
This may be the result of accident or of design, excepting that, in 
the case of the cord, it is never in man the result of design. In 
some cases the peripheral nerves are sectioned by the surgeon in 
an attempt to cure neuralgia. This is an operation which for- 
merly was frequently performed for trifacial neuralgia. Broken 
back (fracture of the vertebra) frequently acts as an interrupter 
of conduction, though, unless it is accompanied by a dislocation, 
it generally does not cause a complete severance of the cord ; so 
that the anesthesia may not be symmetrical nor complete. Coi'd 
tumor, however, is almost invariably accompanied by anesthesia. 
Indeed, Bailey (544) says that no cord tumor can be diagnosed 
with certainty if sensibility is intact. The only exception Bailey 
makes is in tumors of the cauda equina. Syringomyelia fre- 


quently produces changes which interrupt the conduction of touch, 
pain, and temperature. In other disorders, as in transverse myeli- 
tisj a local interruption of the sensory tracts in the cord also 
results in anesthesia. In tabes the sensory fibers are affected just 
as they enter the cord, and analgesia is produced here, although 
touch and temperature conduction may remain intact. Practi- 
cally the only lesion of the posterior roots which causes anes- 
thesia is severance, which generally occurs as the result of frac- 
ture of the vertebra. 

Lesions tvithin the nerve itself may cause an anesthesia. An- 
esthesia may also be the result of pressure within the nerve sheath, 
as illustrated in the case cited by Babcock (549), of a patient 
who had sustained a small incision of the median nerve from a 
piece of flying glass and had an area of anesthesia corresponding 
to the sensory distribution of this nerve. On exposure of the 
injured nerve it was found that it was not divided, but was the 
seat of a marked fusiform enlargement. Upon incision of the 
affected area, a gelatinous, serous fluid flowed from between the 
nerve fibers. A free longitudinal incision was made into the 
nerve. Four days later, upon testing the hand, it was 
found that the area of anesthesia had decreased one-third, 
and that there was a distinct increase in the ability to 
flex the fingers. 

Should a nerve trunk be pressed upon by a tumor, a complete 
interruption of the conduction of nervous impulses may occur, 
and the area of skin distribution cut off will lose all sensibility. 
At the same time the irritation occurring at the level of the lesion 
may cause severe pain, which is referred to the peripheral distri- 
bution of the nerve. A similar condition, called anesthesia dolo- 
rosa^ is often associated with cancer of the spine, the mass press- 
ing upon and irritating the sensory nen^es entering the interver- 
tebral spaces (Eichhorst, 553, Landois, etc.). 

Freezing of a sensory nerve trunk also causes anesthesia. 
This is due to ischemia because, when ischemia is present in a 
part (Kofman, 478), anesthesia generally results. This, in turn, 
may be a result of mechanical pressure or of a chemical reaction 



to toxic factors. In the Glasgow Medical Journal of 1898 
(Vol. L, p. 467) are mentioned the following instances of opera- 
tive procedure without pain, the only anesthetic measure being 
the production and retention of complete ischemia by means of an 
Esmarch bandage. By this method, a ganglion was resected from 
the dorsum of the right wrist without pain, a needle was also re- 
moved, and a ganglion in the popliteal region was resected. In 
such cases it is necessary that the ischemia be complete, and that 
a short time shall elapse between the application of the Esmarch 
and the beginning of the operation. 

Certain toxic agents (as cocain) will produce a terminal anes- 
thesia. Cocain first destroys the pain-conduction power of the 
fiber, and finally touch sensation. In the tongue, according to 
Schree (201, p. 207), the order in which sensation is lost in 
general anesthesia is taste (bitter, sweet, then acid), pressure lo- 
calization, and lastly tactile perception. Temperature sense is also 
abolished (Met- 
tler, 505). Car- 
bolic acid (5 per 
cent, solution on 
the tongue) weak- 
ens the sense of 
pressure and pain, 
but destroys the 
sense of taste and 
temperature. Ar- 
senic and bella- 
donna produce an- 
esthesia to touch 
and pain, but not 
to temperature. Sa- 
ponin produces an- 
esthesia to touch, 
but does not affect pain in any way (Rebot, Mettler, 505). 

Hyperalgesia is a condition in which there is an abnormal 
painful sensibility to irritative processes of any kind. Since 

Fig. 28. — Method of Eliciting Hyperalgesia. 


pain-perception is the specific performance of a definite kind of 
nerve fiber, hyperalgesia may be regarded as a hypersensitiveness 
of the pain nerves (Sahli, p. 771). 

Hyperalgesia of a part may be tested in three ways: 

(1) A rather sharp pin, or pointed instrument, is drawn 
across the surface under examination, the instrument being pre- 
ceded by the finger, as shown in the drawing. The reasons for 
the finger preceding the instrument are: (a) that the sense of 
touch may be somewhat removed, in order that the patient may 
not be so likely to confuse touch sensation with pain sensation, 
and (b) that, by using the second finger as a support, more 
equable pressure with the pin can be made, while at the same 
time all folds of the skin which might cause inequality of pres- 
sure will be pressed out. 

(2) A second method, in which the skin is pinched between 
the fingers, is also a good one, but does not show the slight changes 
in sensibility which are found by the first method; nor does it 
permit of such fine judgments on the part of the patient as to 
the presence or absence of pain, or of variations in the degree 
of pain, because of the inability of the examiner always to exert 
the same amount of pressure in each individual pinch. As far 
as personal choice goes, I have always preferred the first method. 

(3) The head of a pin is sometimes used instead of the 
point. This really gives one hyperesthesia instead of hyperalgesia, 
hyperesthesia meaning an increased sensitiveness to all sensation, 
and hyperalgesia meaning only an increased sensitiveness to pain. 

(4) Instrumental. — Various forms of instruments (esthesio- 
meters, or algometers) have been devised for the purpose of accu- 
rately recording changes in sensory or pain perception. 

In judging of the hyperesthesia of a part, special attention 
should be paid to each of the tissues composing the part, namely: 

(1) The skin (hyperalgesia sought by running the point of a 

pin over the skin). 

(2) The subcutaneous tissues (hyperalgesia sought by grasp- 

ing lightly the structures of the skin between the 
thumb and first finger). 


(3) The muscular tissues (hyperalgesia sought by movement 

of muscles). 

(4) The osseous tissues (hyperalgesia sought by deep pres- 

sure and tapping). 

(5) The serous membranes, such as the pleura or peritoneum 

(hyperalgesia sought by deep pressure, respiratory or 
cardiac movement). (McKenzie.) 

The areas of hyperesthesia of any two of these tissues may 
not be coextensive. The area of tenderness of the subcutaneous 
tissues is generally more extensive than the areas of any of the 
other tissues. Sometimes the areas of the subcutaneous tissues 
which are sensitive may be at some distance from the hyper al- 
gesic areas of the skin. This is explained by the fact that both 
of these areas are supplied by nerves coming from the same seg- 
ments of the cord, but having different distributions (McKenzie). 

Head has made a special study of hyperalgesic zones of the 
skin; that is, hyperalgesia due to pricking with a sharp instru- 
ment, or by pinching a fold of skin between the fingers. Should 
the underlying tissues be grasped, or pressure be exerted upon 
them, the results of the examination are apt to be deceiving, from 
the fact that the sensibility of the subcutaneous tissues is mixed 
with that of the skin. A reflex associated with these hyperalgesic 
zones is dilatation of the pupil. When the irritation is severe 
enough to cause pain, this dilatation is especially noticed on the 
side which is hyperalgesic. Pinching of the areas which are not 
hyperalgesic may, if the pinching is severe enough, cause a dila- 
tation of both pupils, but more marked on the side pinched. The 
hyperalgesic areas are particularly insensitive to deep pressure. 
In many cases touch is not painful, while in others it produces 
the most severe pain. Deep pressure over these areas will also 
produce a dilated pupil more pronounced on the affected side. In 
these areas the sensations of heat and cold are also exaggerated. 

These hyperalgesic areas are sharply defined, while the hyper- 
algesic areas due to a lesion of a nerve or nerve trunk are rather 
vague and indefinite, and overlap. As a consequence, they cannot 


be used to delimit the boundaries of nerve distributions. The 
mere fact that these areas of hyperalgesia (Referred Pain, Head) 
and of extremes of temperature (Forsyth, 26, p. 173) do not 
overlap, seems to show that they have their origin in the cord, 
and bear some relationship to the pain pathways, or at least that 
they arise in the spinal ganglion before the nerve roots unite and 
form plexuses, for it seems that it makes no difference how many 
nerve plexuses and nerves the spinal roots form; the areas of 
hyperalgesia are still distributed on the body in a segmental form. 
This is well illustrated in injuries of the spinal roots, or of the 
cord. Langley (131, p. 235) thinks that a slight rearrangement is 
required in Head's areas, in order to bring the anatomical and 
clinical evidence in accord. He says that "a white ramus always 
has sensory fibers." If so, it could carry sensory impulses, which 
would be so interpreted by the brain. We will not discuss this 
further, but will leave it for consideration under Sensibility of 
the Internal Viscera. 

In some cases of anemia, malaria, and infections of various 
kinds, painful areas are present in the skin. This is particularly 
true of influenza, which sometimes causes a severe general hyper- 
esthesia ; so much so that the slightest touch is painful. The 
scalp may be so affected that the combing of the hair is almost 
unbearable. In some cases lesions of the internal viscera give 
rise to no hyperalgesia until an intercurrent infection, such as 
pneumonia, or possibly appendicitis, occurs. This increases the 
irritability of the cells in the cord, and then the irritation from 
th© diseased focus is felt and is referred to the peripheral distri- 
bution, and continues after the intercurrent affection has disap- 

Hyperalgesia and hyperesthesia do not increase the accuracy 
of localization. Rather, they seem, to multiply and duplicate the 
number of sensations (Mettler, 505), so that the patient, on at- 
tempting to delimit his pain areas, becomes greatly confused. 

Tenderness. — Tenderness is slightly different from hyperal- 
gesia. It means a painful condition produced by pressure. Hy- 
peralgesia, when severe, will also give rise to tenderness, but it 


may also be present and not give rise to pain on pressure. In some 
cases, even a strong, firm pressure is found most gratifying. 
Sometimes there is a dissociation between the tenderness and the 
subjective pain, the tenderness being present over the site of the 
lesion, while the subjective pain may be limited to this area or 
may be referred to a distant area. 

As a rule, pain of equal intensity cannot be felt in two places 
at the same time, for the mind is capable of only a single impres- 
sion at one time. Then, it will be asked, how are we aware of 
the pains over different parts of the body during the course of 
certain diseases (as influenza) ? The answer is very simple. As 
no stimulus can always maintain the same intensity, at times its 
strength will be reduced. At such a. time, another and lighter 
stimulus will gain the ascendency, and will impress its location 
and character upon the brain, and be perceived. This perception 
lasts only a short time, when the first, or some other, stimulus 
again gains the ascendency and impresses its character upon the 
mentality. Thus the localization of the pain varies, from day to 
day, from hour to hour, and from minute to minute, the stronger 
impression being the only one of which the mind is cognizant. 
This also accounts, in some instances, for the variability of pain, 
and for its frequent change of location. In other cases, the ten- 
derness may be felt in a part distant from the lesion. This is par- 
ticularly true when disease or pressure on a nerve is present. 
When such is the case areas of tenderness are generally at the 
points where the nerves emerge from the deeper parts and become 
superficial. To them the name Valleix's points has been given. 

According to Bennett (4Y5), there are three painful reactions 
to pressure. In the first, the pain is increased by pressure of any 
kind. The lightest touch causes the most severe distress. Infec- 
tious diseases of the nature of influenza produce this condition. 
In the second, the pain is increased by deep pressure only. It 
generally indicates some deep inflammatory lesion which is not 
disturbed by the superficial pressure, but is aggravated by deep 
pressure. For instance, in phlebitis, slight pressure over the most 
painful part is not resented, but deep pressure produces pain. 


In th.e third reaction, pain is increased by superficial pressure. 
In this condition, Bennett believes that a vasoneurosis is present 
and causes a dilatation and engorgement of the vessels, especially 
marked in the muscles ; the pain is severe and is relieved by pres- 
sure and massage. On the contrary, if the engorgement is in- 
flammatory, and an exudate is present, the pain will be increased 
rather than decreased on pressure. 

Tenderness may be present over the area in which pain is 
complained of, but which is not the area of the lesion, or it may 
be entirely absent over that area and be found at some distant 
point. A few cases of disease in which the tenderness and its re- 
lation to the location of pain differ are given below (Bennett) : 

Disease Location of Pain Location of Ten- 


Tabes dorsalis. Epigastrium (com- Over the spinal verte- 

monly ) . bra. 

Sciatica. Often back of thigh Over the great sciatic 

and knee. notch. 

Intercostal neuralgia. In epigastrium or in Over the intercostal 

the middle line of spaces, 
the body. 

Gastric ulcer. Opposite the eighth oi Over the gastric re- 
tenth dorsal ver- gion. 

Gall-bladder disease. In the back at the an- Over the gall-bladder 

gle of the scapula. region. 

Rigidity of the underlying muscles is, as a rule, associated 
with tenderness. This is a good confirmative sign that pain is 
present (of some diagnostic value in malingering). Points which 
aid in differentiating the malingerer from the actual sufferer are 
the changes in respiration and pulse, both in the rate and rhythm, 
when pain is produced. These are not absolute, because in some 
cases where there is actual physical objective tenderness no change 
in the pulse or respiration is noticed in making pressure upon the 


tender point or points. Changes in the pupil, however generally 
they occur, should also always be sought, for pain causes dilatation. 
Paresthesia. — This is a term used to describe a group of symp- 
toms simulating pain, yet not of sufficient intensity to be so 
classified. Under it are grouped such feelings as numbness, prick- 
ing, and tickling. They are probably due to a lesser degree of 
irritation than that which produces pain. For instance, pres- 
sure upon the ulnar nerve at the elbow will produce tingling and 
numbness, while a sharp blow will produce actual pain. Like- 
wise, it is common when one knee is crossed over the other to 
have the foot of the crossed leg go to sleep from pressure on the 
sciatic nerve. A fractured lower end of the humerus may also 
press upon the ulnar nerve and cause paresthesia in the ulnar 



Several different classifications of pain might be made, but 
the one most generally used is that which classifies them accord- 
ing to origin, namely, subjective and objective. 


Subjective pains are those which have no physical cause for 
existence, but are a product of mental action arising from some 
changes of the coordinating centers of the sensorium. 

There are a variety of conditions in which subjective pains 
play a great role. The most frequent of these are emotional states, 
hysteria, habitual reactions, depressions of various types, com- 
pulsion neuroses, etc. In hysteria, wherein, owing to intense 
mental concentration on the subject of pain, with the fixed idea 
that it can be and is present in a certain place (ovaries, for in- 
stance), it happens that, subjective to the patient, to all intents 
and purposes, pain is present in such an area or point. Hysterics 
are noted for the rapid changes in the location of their pains ; 
for the great variety of pains with which they are afflicted, and 
their sudden change from those of mild character to those of 
great severity. These pains may have no organic basis for 
their presence, but may be the product of deranged mentality, 
the result of disordered mental equilibrium wherein impulse is 
misinterpreted, and the stimulus which ordinarily would be rec- 
ognized as only a slight irritation is magnified, enlarged, and 
changed in its journey to the sensorium, so that it is felt by the 
centers as pain; or else the centers themselves are diseased, so 
that they interpret normal, non-painful phenomena as painful. 


It is manifest that these ideas of pain, or the snbjective impres- 
sion of pain, are the result of imjDressions stored up in the mem- 
ory centers, which are recalled when the proper associations are 
aroused. These recalled sensations may be either autosuggestive 
or heterosuggestive. 

In autosuggestive sensations the suggestive stimulus arising 
in the organism itself is due to some pathological change, while 
in the heterosuggestive sensations the stimulus arises outside the 
organism, as in hypnosis, wherein pain can be felt in response to 
a suggestion made by the hypnotizer. Subjectively-excited pain 
can be made to appear and disappear at the will of the operator. 
Also, sensations which normally are pleasant may, by the sugges- 
tion of the operator, be interpreted as painful, thus showing how 
a functional misinterpretation may occur without any organic 
basis. These suggested pains often are localized in a particular 
organ, as in the hip joint in cases of so-called hysterical hip-joint 
disease. Here the area corresponds to the terminal distribution 
areas of several nerves, and is not localized to the area supplied by 
the terminal filaments of a single nerve. The projected idea of 
pain comes from the intellectual coordinating center acting in con- 
junction with the memory center. In this respect, the question has 
often been asked, can we conjure up in our dreams the sensation 
and impression of pain ? From recollection of my own dreams, I 
am incapable of answering in the affirmative ; but several of my 
patients have informed me that they have dreamed of being in 
severe pain, which proved to be a myth upon awaking, there being 
present no perceptive irritation which might act as a subconscious 
cause of the pain. This dream-pain has been described as similar 
to the sudden acute and agonizing pain associated with the cut 
of a dagger, or contact with fire, and the sensation is as real as 
though actually occurring. In these cases, it seems as though all 
the tracts from the reception center to the. memory center are 
blocked, except those for touch and pain, and from the memory to 
the ideational center all the tracts except those for pain are blocked. 
Therefore, the ideational center perceives only impressions which 
by the memory center are interpreted as painful. . 


Emotional Pains. — The emotional pains are those which are 
the result of excessive emotion, of any kind. They are felt in 
great anger, great sorrow or distress, and kindred feelings. The 
sensation experienced is not in reality a pain, but rather a feeling 
of unpleasantness. That it is an actuality may be deduced from 
the fact that, upon its disappearance, the body is left in the 
greatest fatigue. Another and a related sensation is the sense of 
depression felt in cardiac disease (angina pectoris). This in- 
creases to anxiety, then progresses through the stage of distress 
until the actual pain is apparent. 

Hysteria. — Hysteria probably includes the largest number of 
subjective pains. It is only recently that hysteria has been recog- 
nized as an entity, and as a disease worthy of the most pains- 
taking attention. Heretofore, when a patient complained of pain, 
and no objective lesion was found, he was dismissed with the diag- 
nosis of hysteria ; but this did not always prevent death from the 
disease with which he was suffering. The absence of a pain in a 
complex of symptoms where ordinarily it would be may also 
lead to a wrong diagnosis of hvsteria. Eoch mentions the case 
of a patient who had stercoraceous vomiting, without the presence 
of pain and tympany, and who was permitted to die without 
operation because of the diagnosis of hysteria. This case illus- 
trates how, because of the absence of pain, hysteria might be 
diagnosed. The same would apply just as well if pain had been 
present and the other symptoms absent. That some change which 
accounts for the pain is present in hysteria cannot be doubted; 
and that the pains of hysteria are imaginary and have no basis is 
ridiculous. As remarked by W. H. Thompson, how is it possible 
for a patient, through imaginary means, to cause a paralysis 
of one voeal cord, when perhaps she does not even know that she 
has such an apparatus, or that it is connected with the formation 
of the voice ? 

Explanation of Hysterical States. — It may be of some service 
to glance over rapidly some of the suggestions made by various 
authors as to the possible explanation for these states. Clevenger 
(40, p. 195), for instance, believes that the anesthesia of hysteria 


is due to deficient nutrition from improper vascularization, the 
result of localized anemia from constriction of the vessels. This 
anesthesia is followed by a return of sensation, and in some cases 
by hyperesthesia or even by hyperalgesia, upon the resumption of 
the blood supply to the part with a consequent engorgement of the 
vessels. The action of suggestion in relieving pain can be ex- 
plained by the lessening of the blood supply to the affected part. 

Sharkey (456) points out, as an argument in favor of the 
central origin for anesthesia in hysteria, that when anesthesia is 
due to an organic disease the patient is aware of his loss, but that 
when it is due to hysteria he is unaware of it. This, according to 
Sharkey, shows that in the first case the psychical centers are in- 
tact, and that in the second case they must be involved so that the 
patient cannot feel pain, and at the same time is unaware of his 

However, the most likely cause of hysteria is some disturbance 
of brain metabolism due to vasomotor changes. In some cases 
there is a transference of the hemianesthesia or hyperesthesia 
from one side of the body to the other. "In these subjects, the 
feeling on the affected side is restored when small metallic plates 
or compresses are applied to the skin. At the same time that 
the affected part recovers its sensibility the corresponding part of 
the opposite, healthy side or limb becomes affected. It was 
thought that the application of the plates produced a galvanic 
current and that this was instrumental in causing the transfer- 
ence ; but it is now believed that it is due to the same thing which 
causes the application of cold plates to one side of a healthy per- 

'■ The cause of this loss may be due to the fact that the nerve cells seem 
to contain a substance of the nature of neurin, which can be transferred from 
one cell to another, in case of exhaustion of one set of cells from hyperactivity. 
Should the cells be unable to replenish their supply of this activating substance, 
they are unable to appreciate impulses, and anesthesia results. Should the acti- 
vating material be in excess, the cells become irritated and respond to less than 
normal stimuli, giving rise to hyperesthesia and hyperalgesia. In some cases 
there are small areas of anesthesia or hyperesthesia over the body. These are 
explained by Sharkey by the fact that after the sensory fibers leave the inter- 
nal capsule they separate and are distributed to widely-separated areas of the 
cortex, so that it would be possible for some of these areas to be affected, and 
thus give rise to areas of changed sensibility. 



son to increase the sensibility of the opposite side" (Landois, 
"Physiology," p. 936, American translation, 1904). 

Distribution of Hysterical Pain. — The area of distribution of 
analgesia in a hysterical subject may follow the distribution of 

Fig. 29. — Areas of Analgesia in Hysteria. 
A is a case of the cerebrospinal type. B is a case of a pure cerebral type. 
In A all superficial reflexes to painful stimuli and to hot and cold sensa- 
tion were lost over the shaded areas. Loss of sensation to touch was 
less extensive. In B the shaded areas indicate the loss of sensation to 
touch, pain, heat and cold. (From Head, Brain, Vol. XVI, p. 116.) 

the cord zones, or of the cerebrospinal areas. The cerebrospinal 
areas generally have sharp boundaries, and have a transverse 
delimitation, as shown in the accompanying figures (Fig, 29, A 
and B), which are taken from Head. These states are inde- 
pendent of any nerve or nerve lesion, even section. They are not 
influenced by inflammation. Frequently these pains make their 
first appearance after the examination of the physician, who, too 
often, by the care with which he goes over an area, and his oft- 
repeated query as to the presence of sensory changes, rather sug- 


gests the pain to the patient. Hysterical pain is also frequently 
induced by emotional shock. Cold, heat, pressure, and irritation, 
as a rule, have no effect upon it. Pressure points — that is, areas 
which are particularly painful to pressure — are frequently found 
in hysteria. According to Dercum (150, p. 849), the most fre- 
quent hysterical areas are: (1) the inguinal region (women), (2) 
the inframammary region, (3) above the spines of the scapula, 
(4) to the sides of the dorsal, cervical and lumbar vertebra, (5) 
over the sacrum, and (6) over the coccyx. 

Diagnosis of Hysterical Pain. — In the diagnosis of such a con- 
dition, the limitations of the fields of vision and the loss of the 
pharyngeal reflex are of considerable weight. Diller (55Y) classi- 
fies the evidence as negative and positive. Under the negative 
evidence, he cites the facts that the pain does not conform to any 
one organic disease, and that it is very contradictory in its charac- 
ter, time, appearance, and duration. Under the positive evidence 
is the fact that suggestion often relieves pain. The patient gener- 
ally is very detailed in his description of the location, time of 
appearance, type, and intensity of the pain. The sufferer from 
real pain, on the contrary, makes but few remarks concerning his 
pain, and when he does so they are generally brief and to the point 
(Thompson). Hysterical pains are not, as a rule, relieved by 
drugs, such as morphin, while organic lesions are so relieved. 

While in many cases a patient may seem to be complaining 
of a pain in order that he may arouse the sympathy of those inter- 
ested, we, as examining physicians, should not conclude because 
we are unable to find an organic basis for the pain that it does 
not exist. The diagnosis of hysterical pain is often but a cloak 
under which the physician hides his ignorance. When we con- 
sider that the nervous system is of considerable volume and 
weighs about six pounds, and that it is subject to the same varia- 
tions of nutrition and change as are the other tissues of the body, 
it is easy to appreciate how it may be subject to the vicissitudes 
of the other tissues, and therefore subject to irritation and fatigue, 
the same as are these tissues. In children, hysterical pain is very 
rare, because they are too young to have experienced much pain, 


and hence are free from pain memories, and, as a consequence, 
are also free from hysterical pain. 

Hypnosis. — Hypnosis is sometimes capable of bringing into con- 
sciousness the stored-up pain experience of the subject. It causes 
those dim and forgotten sensations which have been present in 
the past to dawn into consciousness. It is only the drawing away 
of the veil from the subconscious state and the forcing of it into 
view. The hypnotizer can suggest the idea of pain to the hypno- 
tized, and can make him feel pain in every act and every move- 
ment. He reproduces, as it were, the states which are present in 

Habit Pains. — A condition closely related to the foregoing is 
that of the so-called habit pains. This is the name given to that 
great class in which the pathways for pain have been so grooved 
from frequent repetition that on the least provocation the stimulus 
travels over them and gives rise to pain sensation. These fre- 
quently follow a trauma which has occurred some time previously. 
Such a trauma may cause abnormal or unusual susceptibility to 
pain production, and what otherwise would be felt as a non- 
painful stimulus gives rise to pain. Habit-pains frequently per- 
sist after operations of various kinds which have been undertaken 
because of the pain, and continue in spite of the fact that all the 
abnormalities have been corrected. The persistence can only be 
accounted for upon the habit-pain hypothesis. The pain is par- 
ticularly apt to persist when opiates, such as morphin, have been 
given before the operation. 

Monomania Pains. — Brissaud (Progres Med., XIX, ISTo. 2) 
mentions another variety of habit-pain, in which the pain recurs 
as a habit at a certain time, or in connection with certain objects. 
Brissaud believes that patients subject to such pain are suffering 
from an obsession, and that they have a delusion of pain when none 
is present. The pain resembles that due to occupation neuroses, 
and represents a variety of pain caused by overactivity of a certain 
neuromuscular apparatus, and nature's attempt to hinder excessive 

Occupation Neuroses. — Dr. Walton ("International Clinics," 


Vol. IV, p. 261, lYth series) recites several cases in which, in- 
stead of the muscular spasm (found in certain neuroses, such as 
writer's cramp), severe pain is felt, not localized to the distribu- 
tion area of any nerve, but rather extending over the area of the 
muscle and its insertion. This pain is induced only by making 
the occupation movements, and is not invariably produced even 
then. If the occupation is continued, every repetition of the act 
causes pain. By this time, the pain is produced by other move- 
ments than those of the occupation, and finally spontaneous and 
paroxysmal pain is apt to appear in the same region, not generally 
following the exact tract of any nerve, but rather distributed over 
the area involved in the muscular action, and perhaps radiating 
therefrom. Tenderness may or may not be present. Examples: 

(1) Physician, laryngologist ; pain in the side of the neck 

and back of the ear ; comes on when the head is placed 
in the position for operating; relieved and finally 
cured by rest. 

(2) Golf player; pain in the arm in the region of inser- 

tion of the deltoid, produced at each swing of the 

(3) Pain in arm; persistent with paresthesia ; due to sewing. 

(4) Music teacher (piano); pain in right arm; numbness 

and easy tiring of the fingers ; relieved on stopping the 

(5) Pain in the entire forearm; due to overwork of the arm; 

moderate tenderness over the entire forearm present. 

(6) Ticket agent; pain and tenderness on the radial side of 

the first phalanx of the ring finger of the right hand, 
due to pressure made by the corners of the tickets 
against the spot in stamping. 

As is remarked in an editorial in the Journal of the American 
Medical Association (LVI, 12, 898), all of the occupation pains 
may be avoided by proper precautions — and as examples are given 
the cure of the pains in the bricklayer's back by placing the bricks 
on a proper platform easy to be reached, or of the hammerer who 


is relieved of the pains in his arm by using the opposite arm in 
his work. 


Bj objective pain is meant that pain which is excited by some 
cause or agent foreign or abnormal to the area in or near which 
it is excited. Such a pain may be produced: (1) in the centers, 
as the brain or cord, and (2) in the nerves, as the trunk or its 
terminations. It always is the result of some demonstrable patho- 
logical change. 


The cortical brain tissues contain no known pain-receptors. 
Pains in the head, about the head, etc., are due to peripheral action 
usually upon the receptors of the trigeminus, widely distrib- 
uted in the meninges covering the cerebrum. The pain of 
pressure within the head, as in hydrocephalus, brain tumor, 
lead encephalopathies, etc., is probably also carried through the 

Purely cortical lesions are not known to produce pain, nor are 
they known to bring about any increase or decrease of sensibility 
to measured painful stimuli. Only in the case of recent lesions, 
or in those accompanied by epileptiform seizures, has there been 
found to be any reduction in pain sensibility. The cortex as a 
place of origin for central pains may be excluded. The role of the 
cortex in the analysis of other forms of sensibility does not lie 
within the province of this chapter. 

Central pains, however, may be present and due to lesions 
in the optic thalamus, which is the chief sensory organ of the 
brain; the major relay station. 

Two features stand out in thalamic lesions so far as sensations 
are concerned. One consists in the excessive response to affective 
stimuli. There is, as Head and Holmes express it, an "overload- 
ing of the feeling tone." It has been present in the thalamic 
syndrome cases reported by Roussy and others (Jelliffe, "Tha- 
lamic Syndrome," N. Y. Med. Jour., 1910)., This excessive re- 
sponse — explosive laughter, explosive crying — bears no relation 


to the quantity of painful stimuli. It is an interesting feature 
that such variations in effective response may be unilateral. 

Thalamic pains are usually very severe and intractable. They 
are not infrequently seen in hemiplegics who also suffer from 
thalamic lesions. Lesions of the thalamus seem to permit all 
sensory stimuli to be felt as painful. Most of the reported tha- 
lamic pains have been located in the upper extremities. 

Lesions about the cord, meningeal exudates, pressures, tabes, 
tumor, give rise to pain. Such are, for the most part, due to 
action upon the peripheral sensory neuron. They are not, prop- 
erly speaking, intracordal lesions, and do not, as a rule, give rise 
to local pain. Pain tracts may be cut off, as in syringomyelia, 
hematomyelia, intracordal tumors, etc., but do not give rise to pain. 
They cause hyperesthesia, and may lower the threshold to painful 
stimuli, but apparently do not cause spontaneous pain. 


Peripheral pains are those which are due to action on the axis 
cylinder, the ganglia cells or the receptors, and are objective in 
that some definite lesion (as a rule) acts as the producing factor. 
They may be classified as to cause, manner of propagation, time, 
constancy, and character. 

Causes. — The causes of peripheral objective pain may be di- 
vided into organic and functional. The organic causes are those 
which are due to changes in structure, or in the relationship of 
different anatomical elements to each other. They may in turn 
be divided into intrinsic and extrinsic. The intrinsic causes give 
rise to parenchymatous pains, and include inflammation, new 
growths, muscular contraction, or displacement of parts, as in 
those cases where teeth have not erupted and are still in the 
maxilla, and where, by pressure upon the adjacent structures, 
they cause great pain. The extrinsic causes include all lesions 
making pressure upon the nerves or nerve terminals, as displace- 
ment and pressure by adjacent organs, new growths, etc., and 
stretching of the nerves, ligaments, or other attachments, in dis- 
placement, or in new growths of different organs. . 


The functional pains are due to excessive activity of an organ 
(generally the activity is transitory), as in the stomach (pyloric 
obstruction) ; in the intestines (obstruction) ; in the testicles (hy- 
persexual activity) ; and in the brain (excessive mental work). 

Pauenchymatous Paijn^.- — Parenchymatous pain is due to 
some pathological condition that involves the sensory nerve termi- 
nations. It may be due to local irritation, such as occurs (1) in 
inflammation, (2) in torsion or stretching of the fibers by muscu- 
lar contraction, (3) in thermic irritation, as in burns, and (4) 
in chemical changes due to acids. 

(1) Inflainmatory Pain. — An organ consists of: (1) the 
essential structure, such as cells; (2) the supporting structure, 
consisting of connective tissues, in which are found (a) lymph 
channels, (b) blood vessels (arteries, capillaries, and veins), and 
(c) nerves (sympathetic and cerebrospinal) ; (3) the encapsulat- 
ing structures (capsules) ; and (4) the adjacent structures (lymph 
glands, nerve plexuses). Therefore, when the pain is parenchy- 
matous, it must occur in one or more of the structures enumerated 

In inflammation we know that the first sign of the beginning 
process is in the blood vessels, which dilate and thus bring an 
additional supply of blood to the part. It is, no doubt, the vast 
increase in the blood supply and the greatly increased force of 
the systolic impulse in the diseased area that cause the throbbing 
pain, recognized as the early stage of an active, inflammatory 
process. It is, however, very difficult to say exactly through what 
channels or means the knowledge of this increased blood supply is 
conveyed to the sensorium. It may be conveyed by the following 
means: (1) nerve fibers distributed to the vessel walls which are- 
associated with the vasomotor nerves; (2) nerve fibers distributed 
to the cellular substance; and (3) i;ierve fibers distributed to the 
capsules of the gland. 

We know that the lumina of the vessels in inflamed areas are in- 
creased much beyond their normal size, so that the combined area of 
the lumina of the vessels within the inflamed area is several times 
the area of the lumina of the vessels entering the part; and the 


systolic pressure is as much greater in the part as the area of the 
vessels in the part is greater than the area of the vessels entering 
it. This is according to a well-known principle of mechanics. To 
be more definite, we may assume the area of the lumina of the 
entering vessels to be one square foot, and the area of the lumina 
of the contained vessels to be twenty square feet. The pressure 
on every square foot of the enlarged area is the same as that on 
the small area. Therefore, it will be twenty times the smaller 
pressure (for example, if the smaller is one pound, the larger will 
be twenty pounds). Thus, it is easy to understand how the in- 
creased area of the vessels will indirectly cause the sensation of 

Vessel entering part 

. —Area thirty times that of 
small vessel entering 
the part 

Area of vessels In inflamed part 

Fig. 30. — Method of Pain Production in Inflammation. 

throbbing. It would, further, cause compression of any nerve 
fibers which are found in the organ, and would also undoubtedly 
exert a great pressure upon the capsule. Both of the factors would 
produce pain. 

The cause of the throbbing in severe inflammation may be 
the impulse of the blood in the dilated vascular paths in the 
inflamed area, or the result of a nervous vasomotor reflex, caus- 
ing an alternating dilatation and contraction of the vessel walls. 
Personally, I am inclined to the belief that it is due to the 
propulsion of the blood into the part without any means of re- 
turn, the capillary paths being blocked, and permitting but slight 
venous return from the inflamed area, or that the return is so 
slow that the blood accumulates in the part. As a consequence, 
the force exerted through the small vessels entering the area 
acts as in a hydraulic force-pump, and the pressure and force 
are increased in the much larger area which the vessels supply. 
Thus, this magnified force is seen by the alternate pallor and 


flushing of the part. The nerves in the part are stimulated by 
the dilatation of the vessels in the area adjacent to the inflamma- 
tion, and impulses are sent to the cord, which sends them back 
again as reflexes, which act as vasomotor dilators. Thus, there is 
dilatation at each systole and a consequent contraction at each 

In the later stages of inflammation the throbbing pain which 
was originally present is changed to a dull ache. This is due to 
the fact that, at this time, the vessel walls and the capsule are 
dilated to their fullest extent, and will not admit any more blood ; 
and, instead of the intermittent, systolic pressure that is found in 
the early stages, there is present a pressure that is constant and 
unvarying. Again, as the inflammation begins to subside (pro- 
vided the extravasated blood does not block the channels) the 
former throbbing pain may recur. 

Sometimes it is found that the inflammatory reaction is not 
limited to the confines of the organ in which it is found, but ex- 
tends beyond these limits and progTesses in the course of the 
adjacent lymph paths, finally reaching some of the neighboring 
lymph glands, where the inflammatory process becomes active, 
thus producing further pain. 

In some cases parenchymatous pain radiates in various direc- 
tions from its place of origin; this radiation may be explained 
upon one hypothesis : that the painful impulses are conveyed 
from the organ to an adjacent nerve plexus where they be- 
come diffused. From the plexus the impulses are carried to 
the brain, and give rise to the impression that the pain arises 
in the entire area to which the nerves forming the plexus are dis- 

Parenchymatous pain, due to inflammation of viscera, seems 
to be more of a myth than an actuality, for, since it is a fact 
that no sensory nerves are distributed to the parenchyma of vis- 
cera, it is difiicult to understand how, in the organ itself, painful 
sensations can be present. The following are instances (Mc- 
Kenzie) illustrating the absence of pain in diseases of certain 
viscera : 


(1) Kidney inflammation, especially the chronic variety, is 
entirely painless. 

(2) Disease (inflammatory) of the liver is v^ithout pain, as 
a rule, and the pain which is present in hepatitis is often due 
either to involvement of the capsule or to the tractions made upon 
the abdominal wall by the pull of adhesions passing between 
the liver and its parietes. The only exception is hepatitis syphi- 
litica (ISTeusser). 

(3) Lung tissue lacks pain-sensation, and in disease such as 
pneumonia the patient is entirely unaware of the baneful changes 
occurring in the lung until the pleura becomes involved and pain^ 
is produced. 

(4) The testicle is also without pain-sensation. Yet orchitis 
is a condition which is very painful ; but it seems that the painful 
reaction in this disease is due to an extension of the inflamma- 
tory process to the adjacent structures (epididymis). 

(5) The heart is also without a local pain reaction. It seems 
that in painful cardiac diseases the painful condition is due to 
an inflanmiation of the myocardium producing pain which is re- 
ferred to the anterior thoracic wall. 

Characteristics of inflammatory pain are: (1) the pain is 
produced on pressure; (2) movement of the part aifected or of 
any adjacent part, causing pressure on the inflamed area, causes 
pain; (3) the function of the part (because of pain) is abolished, 
as the rigidity of the hip, which occurs in hip-joint disease (see 
Ryder, 35). It has been observed that inflammatory pain is 
more intense in colon-bacillus and streptococcic infection than in 
most other infections. 

Parenchymatous pain in glandular organs, such as the lymph 
glands, may be due to stretching of the capsule or to involvement 
of the nerves which accompany the arteries into the part. In 
glandular tissue there does not seem to be any parenchymatous 
nerve supply other than these filaments which accompany the 
blood vessels to their ultimate divisions in the depths of 
the tissue. In acute infectious diseases the pain is due to irrita- 
tion of the terminal nerve filaments by the toxic substances circu- 


lating in the blood. The reason for the pain being localized in a 
particular area is that in this area the tissues are in a state of 
lessened resistance and any toxic change taking place will be local- 
ized in the less resistant region. 

(2) Traction, that is, stretching or pulling on the nerve 
fibers by muscular contraction, may cause pain. This is exempli- 
fied in the contractions of the stomach, intestines, gall-ducts, ure- 
ters, and uterus. It seems that the most severe pains felt by 
patients are those due to contraction of hollow viscera, such as 
the intestine gall-ducts, ureters, etc. 

Torsion of the nerve fibers, such as occurs in twisting of the 
pedicle of an ovarian cyst, also causes severe pain. 

(3 and 4) Thermic and Chemical Irritations. — Burns, from 
heat or chemical agents, cause pain by exposing the sensory ter- 
minal filament to irritation by external agents. Even exposure 
of these filaments to the air causes the most excruciating pain. 
The reason for this, in all probability, is that, because of their 
sudden change from a medium where temperature and surround- 
ings are equable to a location where these conditions are not favor- 
able, a great change in their state of irritability is produced, so 
that they respond to a greater degTee than normal to all stimuli, 
and especially so to stimuli to which they had not been previously 





Propagation of Pains. — The second part of our classification 
deals with propagated pains. These pains are felt in areas 
other than those in which they are produced. They may be 
divided into associated, referred, projected, reflex, and trans- 
ferred pains. 

Fig. 31. — Vakieties of Pain: Origin and Transmission. 




Associated Pain. — The associated pain depends, for its 
production, upon the transference of stimuli from one nerve cell 

Ascendinqand Crossed Fibre -Pain 
- -is perceived as coming Iroitl the 
opposite side of the body and at 
lower level. 

Inftrmcdiate Neuron, 
connedinq two sejmenis 
of the cord 

■■B^nsfertnce Fibr* 

..Prevertebral Ganglion 

^■Subsidiary Ganglion 

^,.'-Terminal QangliOR orFibre* 

Fig. 32. — Scheme Showing How the Different Varieties of Pain May 



to another. In some cases it is impossible to tell bj what means 
the stimuli are transferred, as in the following cases : 










(1) A pain in the top of the head occurred with rectal fis- 
sures. Upon the curing of the fissures, the pain disappeared. 

(2) Pain under the heart, associated with labor pains. In 
this case there was also cutaneous tenderness, which came and went 
with the labor pains. 

(3) Epigastric pain associated with gastritis. 

(4) Pain in knee in a case of putrescent pulp of the lower 
second bicuspid. Upon drawing the tooth the pain was relieved. 
Upon sealing it again, after it had been opened and drained, the 
pain returned. This experiment was made several times with like 
results (P. V. McFarland). This pain reference is also present in 
those cases where two adjacent centers are involved. 

If the original stimulus is very severe, and is continued long 
enough, adjacent centers become irritated, owing to the central 
stimulation by the overlapping or spilling of stimuli from the ad- 
joining centers to which the stimulus is conveyed. This is exem- 
plified in the ear pain which follows toothache, or in the pain in 
the inframaxillary branch of the fifth nerve when the stimulus is 
in the superior maxillary branch. In some cases the pain be- 
comes very difi^use, and is felt over wide and scattered areas of the 
body. The diffusion is accounted for in two ways : 

(1) By the crossing of the fibers. Some of the sensory 
fibers evidently pass over from one side of the cord to the other, 
conveying impulses which stimulate the sensory cells (in the cord) 
supplying the opposite half of the body. 

(2) By the diffusion of the stimuli. Some of the nerve cells 
in the cord are in close relationship with those cells to which the 
stimuli from the painful parts are carried. When there is an ex- 
cess of stimulus, some passes over into the neighboring cells and 
gives rise to painful sensations, which are interpreted as coming 
from the area supplied by the stimulated cells. This tendency to 
diffusion may be due : 

(a) To reduction of the resisting power of neighboring seg- 
ments, ''general constitutional diseases reducing the body powers 
generally, and the nervous system in particular, as in anemia and 
pulmonary tuberculosis." 


(b) Increasing excitability of the involved segment, as in 

(c) Prolonging or .Augmenting the stimulating power unduly, 
as in chronic ovaritis and chronic metritis. 

These diffusely distributed pains should not be mistaken as 
manifesting hysteria or hypochondriasis. In some cases the diffu- 
sion is so great, and the pains so general, that they are spoken of 
as generalized pains. (This is particularly so in the various in- 
fectious diseases.) In other cases, when a distant segment of the 
cord, or even the pain centers in the brain, have a reduced resisting 
power, or have had the pain habit, irritation in any part of the 
body may sensitize these centers and cause the pain to appear to 
come from their areas of distribution. From Fromentel's studies 
(Monro, 556) it appears that the relationship between the irri- 
tated point and the sympathetic point is very constant and that 
the sympathetic point is generally on the trunk on the same side 
of the body. Cases in point are : 

(1) "Mrs. H., aged 44; married late in life and never was 
pregnant. Health has been fairly good. Several years ago she had 
an attack of acute otitis media, the result of chronic otitis media 
in the right ear. For some time the patient has suffered from 
dysmenorrhea, but the pain from which she suffers has been in 
the right ear and has been very severe. I was called to see the 
patient, but before I got to her house the pain had ceased. The 
patient visited me at my office. Bimanual vaginal examination 
showed an enlarged and very tender left ovary, pressure upon 
which caused quite severe pain in the ear" (personal communica- 
tion from Dr. Torrey, Olean, New York). 

(2) Pain in the chest, right side anterior, from rubbing the 
back of the right forearm. A touch on the back of the forearm 
or any part of a strip of surface extending from below the elbow 
to the four iimer metacarpo-phalangeal articulations was felt both 
locally and in the area described on the anterior of the chest. 
Firm pressure on the part of the arm described caused no pain 
locally, but caused severe tearing pain in the chest front (Monro, 
32, p. 9). 


(3) Pain in the chest, clue to pressure at the front of the wrist, 
at the root of the thumb, or at the flexure of the elbow on the left 
side. The pain caused was not local, but was felt in the left lateral 
region of the chest (Monro). 

(4) Pain was present in the chest on the right side, over the 
second right costal cartilage, during each dressing of an ajDpendi- 
ceal abscess wound. 

(5) Painful stimulation of the thigh produced a pain in the 
back of the head (Monro, 32, from De Fromental, "Les Synalogus 
et les Synalgia"). 

(6) Mitchell quotes a case where stimulation of a mole on 
the leg produced pain in the chin. 

(7) The headache which occurs after eating ice cream is also 
an illustration of this variety of pain. 

(8) The headaches which occur in various diseases are also 
illustrative of this condition. 

(9) Alger (560) reports a case of severe abdominal pain, 
resembling that due to appendicitis, caused by eye-strain. Upon 
the adjustment of glasses, the pain disappeared. Three years 
later the patient lost his glasses, and the pain immediately re- 

In some cases the associated areas are physiologically related, 
as the breast and uterus (see mammary gland). It is- very com- 
mon for women to have j)ain in the breast during the period of 
menstruation. In many cases it occurs just prior to menstrua- 
tion. This pain-localization may be due to lessened resistance 
or increased irritability in the nerve-conducting paths, the stimu- 
lus which in one gives rise to pain, in another produces no reac- 
tion; or there may be some unusual nerve connections between- 
these diiferent parts, or some cryptogenic process may lie dormant 
in the parts and announce its presence by pain on irritation of 
some related part. In woman, the spinal area offers least resist- 
ance to pain at the sixth dorsal (mammary) ana the tenth dorsal 
(ovarian) vertebra. 

Misreference of pain phenomena, because of the instability 


of the nervous system and the imperfect development of the local- 
izing apparatus, is very common in children. Examples of this 
are seen in the pain present over the appendix area in cases of 
pneumonia and hip-joint disease. 

Referred Pain. — Referred pain is the name given to that 
class of pain in which the irritation occurs along the course of 
the nerve fibers, and the pain is felt as being produced in the 
somatic peripheral distribution of the affected nerve or nerves. 
There are three places w^here the irritation may cause referred 
pain, namely: 

(a) The cord. 

(b) The posterior roots or ganglia. 

(c) The nerve trunks or nerves. 

When the irritation occurs in the cord, the pain sensation is 
referred along the pain paths connected with the same side of the 
body. When it is transferred across the cord, and is felt on the 
opposite side, it is called transferred pain. Among referred 
pains, due to disturbance in the cord, are the well-known girdle 
pains, which are almost pathognomonic for tabes dorsa lis , trans- 
verse myelitis, cord tumors, etc. Referred pains from lesions on 
the posterior roots may be due to pressure from fragments of a 
fractured vertebra, tumors, or inflammation, as in meningitis and 
herpes. The principal causes of referred pain, however, are 
lesion^ occurring somewhere on the nerve circuit. They may 
occur on the nerve trunk or on one of the branches (see illustra- 
tion). When a lesion occurs on the trunk, it is always referred 
to a point on the periphery distal to the area at which it occurs ; 
but if the irritation is on a branch, it may be referred to the 
periphery in an area proximal to that at which it occurred. This 
is due to its reference along a collateral branch. Bennett (48) 
gives a number of cases in which pain in the groin was due to 
both downward and upward reference. 

The following is a table taken from Dr. Bennett's article 
(p. 269) : 




Incidents of Pain in Groin 
Apparently from Above 


Prolapse of ovary 1 

Omental umbilical hernia. 1 

Tumor of tbe pelvis 1 

Stone in the bladder 1 

Stone in the ureter 3 

Stricture of the urethra. . 2 

Movable kidney 1 

Cyst of the testicle 2 

Retained testicles 3 

Intestinal diverticulum ... 1 
Incomplete inguinal hernia . 2 

Traumatic lumbar hernia 1 

Varicocele 3 

Lateral curvature of the 

spine 2 

Spinal abscess 1 

Undetermined 2 

Incidents of Pain in Groin 
Apparently from Below 


Small omental hernia. ... 1 

Small femoral hernial sac. 1 

Obturator hernia 1 

Saphenous varix 4 

Osteoma of the tibia 1 

Femoral atheroma 2 

Osteoarthritis 1 

Rider's sprains 4 

Polypus of the rectum .... 2 

Piles 2 

Flat foot 1 

Popliteal sarcoma 1 

Old fractured tibia 2 

Melanotic mole on the sole 

of the foot 1 

Varicocele 2 

Dr. Bennett also speaks of a case of osteoma of the tibia, in 
which a sharp spicule of bone sprang from the inner surface of 
the bone, about four inches from its lower end. Pressure upon 
this caused acute pains in the left groin, rather to the inner side. 
Pain also occurred when the limb was being flexed, as well as 
when it was rotated outward. Kicking also caused pain. It was 
due to involvement of a filament of the saphenous nerve. 

Another case mentioned by Dr. Bennett is that of a pain in 
the knee caused by a corn. In this case, a loose semilunar car- 
tilage was diagnosed, and the advisability of an operation was 
considered. The patient had sudden attacks of acute pain, most 
marked when he would suddenly turn around. These pains were 
present when he wore boots or shoes, and were entirely absent 
at other times. 

A most peculiar case was one in which pain in the groin was 


caused by a mole on the foot. Pressure iipon the mole, which 
was on the inner side of the foot, caused pain in the front of the 
groin. Other cases of upward reference are: 

(1) Pain in the back caused by a wound of the testicle (Wit- 
mer, 527, p. 930). 

(2) Pain and tender areas over the fourth and fifth spinal 
segments in painful disease of the breast (Treves's "Applied An- 
atomy," p. 176). 

(3) Pain in the left clavicle in volvulus of the small intes- 
tine; condition verified by autopsy (Haworth). 

(4) Pain in the back, due to a wound of the testicle (S. W. 
Mitchell, 559). 

Cases of downward reference are : 

(1) Pain in the arm and hand from pressure on the brachial 
plexus by a su23ernumerary rib. 

(2) Pain in the little finger due to pressure on the ulnar 
nerve from a growth on the first rib (Forsyth, 126, p. 1470, quot- 
ing from Hilton). 

(3) Pain in the left leg, in a case of tubercular disease of 
the spine, with a sinus opening in the lumbar region. Upon 
passing a sound into the sinus, the patient complained of severe 
pain shooting down the leg (St. Francis Hospital Dispensary). 

(4) Pain in the hand, along the outer (radial) side, from 
irritation of the musculospinal nerve due to fracture of the upper 
part of the middle third of the humerus (Estes, 555). Estes 
also mentions the pain felt on the ulnar side of the hand, especially 
in the little finger, in cases of bone excrescences, etc., about the 
inner condyle of the humerus. 

(5) Pain in the thigh (anterior and posterior) and in the 
groin, from a psoas abscess. This case I shall give in detail be- 
cause of classical reference of the pain. 

The patient had been sick for some weeks, and recently com- 
plained of pain in the posterior region of the leg. The point of 
maximum tenderness was beneath the crural fold in the crural 
crease. He also complained of pain in the area outlined in Fig. 34. 
There was a fullness present in the inguinal region, which was 


tender to the toucli. On irritation of a narrow area of the skin 
next to the scrotum, a reflex contraction of the abdominal wall 
was noted in the area indicated in Fig. 35. This reflex was pres- 
ent on both sides. There was also noted rigidity of the spine, 
Sayre's test positive, Bryant's angle normal. When lying on the 
back or side, the knee was flexed and the thigh but slightly flexed ; 
there was fullness in the left inguinal space glands, as indicated ; 
the circumference of left thigh was 1.5 inches more than the 
right one. This condition gTadually progTessed until opera- 
tion, several days later, when a large collection of pus was 
found in the inguinal region, which ajDparently came from the 
region of the spine. After operation, the patient quickly col- 
lapsed, his temperature became high, and he died in twenty-eight 

It is interesting to speculate upon the reason why pain should 
be felt in the area indicated. A study of the anatomy shows that 
the area of pain is the area of distribution of the small sciatic 
nerve, which was involved by the abscess cavity as it gradually 
crept downward into the thigh. The reflex contraction of the 
lower abdominal wall occurred in the area of distribution of the 
first lumbar segment, and the irritation which produced it was 
made in the area of distribution of the ilio-inguinal, which is also 
derived from the first lumbar segment (Fig. 36). Therefore, 
the first lumbar segment of the cord in this instance acted but as 
a reflex station for the neiwes which derived their origin from it. 
The sudden death of the patient, in this case, could only be 
explained by the supposition that the system was overwhelmed by 
toxins which were more easily absorbed when the pressure was 
taken away from the cavity walls on the opening of the abscess. . 
Still, this is a rather far-fetched explanation. 
Other cases of downward reference are: 

(1) Pain in the epigastrium, due to disease of the spine, 
with a slight displacement between the sixth and seventh ver- 
tebrge. In this condition, the pain increased when the patient 
assumed an erect position, and, as a consequence, he walked with 
the body inclined forward (Hilton). 









■2 3 

■O 60 



















(2) Pain in tlie chest, in the distribution of the fourth and 
fifth dorsal nerves, from an aneurysm of the aorta (Hilton). 

(3) Pain in the penis from ureteral colic and from cystitis. 
In one case the patient, who had a stab wound one inch below the 
umbilicus, complained of pain in the penis each time the gauze 
packing, which touched the bladder, was removed. The rectum 
and the neck of the bladder are supplied from the second, 
third and fourth sacral nerves. From the same nerves the 
pudic nerve, supplying the penis, is derived, and thus is ex- 
plained the pain in the penis, due to rectal or vesicle disorder 
(Monro, 32, p. 7). 

(•i) Pain in the g-reat toe on the left side, in a patient suf- 
fering with perinephritic abscess, the sinus from which opened in 
the lumbar region a half inch from the second lumbar vertebra. 
Pain was noticed onlv when the cavity was full of solution 
(E. C. Stuart, personal report). 

(5) Disease of the anterior third of the tongue frequently 
causes pain in the auditory canal, because the auditory canal, the 
teeth, and the anterior part of the tongue are all supplied by the 
fifth dorsal nerve (Monro, 32). 

(6) Pain in the legs, which was very unresponsive to treat- 
ment, was found to be due to a tumor of the cauda equina. 

(7) Monro (32, p. 7) also gives an example of a case of hemi- 
plegia in which the patient, who had almost complete anesthesia 
of the genitals, suffered pain in the great toe every time he passed 
urine. This is explained by ]\Ionro as due to the common origin, 
from the first sacral nerves, of the nerves supplying the dorsum 
of the gTeat toe and those supplying the prostate and the mucous 
membrane of the neck of the bladder. 

(8) Pain in the calf of the leg may be present in prostatic 
disease (Head, "Brain," 16, p. 29). 

(9) Severe earache may also be found occasionally in ton- 

(10) Pain on the inner side of the ankle was due to a tumor 
in Scarpa's triangle. 

The following are characteristics of pain due to pressure upon 


a nerve trunk by a tumor, enlarged and displaced organs, or other 
causes : 

(1) The pain is continuous, and does not intermit, as in 
neuralgic pain. 

(2) It is not increased upon pressure or movement. 

(3) It does not produce muscular stiffness, differing in this 
respect from inflammatory pains. 

(4) It may interfere with function, as in brain tumor or 
brain abscess. In the former there is no fever, while in the latter 
fever is present. 

(5) It radiates very widely, especially when large trunks or 
plexuses of nerves are involved. A characteristic of radiating 
pains is that they vary greatly in intensity and location, but that 
they are always associated with other pains which are due directly 
to the lesion or radiate from it. A study of the different varieties 
of radiated pain will give us a clew to the focus of the disease. 

(6) Tumor involving the trunk of a nerve sometimes causes 
trophic changes at the peripheral distribution of the nerve on the 
skin, in the form of an intractable ulcer, or as a herpetic eruption 
followed by persistent local anesthesia. 

(7) Cramps in the muscles may be associated with pressure 

(8) A point of interest in connection with these pains is that 
morphin does not ease them for any considerable time, but "anti- 
pyrin, phenacetin, and other coal-tar derivatives are of consider- 
able service, either combined with an opiate or with bromids. 
This is especially true in pains caused by aneurysm" (Thompson, 

In cases of section of nerves, J. K. Mitchell remarks that occa- 
sionally, after union of the segments has taken place, the sensa- 
tions of touch and pain are. referred to the wrong areas. He sug- 
gests, by vvay of explanation of such cases as depend upon nerve 
injuries, that possibly, in the union of the several nerve trunks, 
the axis-cylinders in the proximal part do not always succeed in 
joining the proper axis-cylinders in the distal portions. For in- 
stance, after a lesion of the nerves in the upper arm, nerve fibers 


from the proximal stump, which normally convey sensations from 
the elbow lesion, may unite with fibers from the distal part and 
with nerves which are anatomically connected with the hand. 
Thus, the impression due to a touch on the hand will, on reaching 
the seat of injury, be shunted to the path which has hitherto 
been that for impressions from the elbow. However, the sensorium 
soon learns to orient the sensations so they are referred to their 
proper source. 

A differential diagnostic point between referred pain and neu- 
ralgia is that in referred pain no nodal points are present (J. H. 
Musser, 558). Apropos of this subject, and bearing upon the 
production of pain, Carleton (123) reports cases of referred, 
transferred and reflex pain, in which relief was obtained by the 
local application of adrenalin, either over the terminal nerve 
filaments or in the course of the nerve. It is difiicult to under- 
stand the modus operandi of this relief, because it is not reason- 
able to suppose that adrenalin, when locally applied, can have any 
but a local action; and if it does have only a local action, how ig 
it possible that it can affect the seat of production of the pain, 
which may be some distance away, on the same nerve or on an 
entirely different nerve, either on the same or on the opposite side 
of the body ? It may be that the application of adrenalin pro- 
duces some effect on the nerves, so that the transmission of pain- 
ful impulses is inhibited. Carleton supposes the effect to be due 
to a regeneration of the nerve force, or rather the restocking of 
the nerve with kinetoplasm, the substance consumed in the nerve 
cells during their activity. How it does so is to me incompre- 

Sympathetic Pain. — Closely resembling transferred pain is 
sympathetic pain. It is really a transferred pain, with the dis- 
tinction that in sympathetic pain a painful sensation is present 
in the organ originating the pain, while in transferred pain there 
may be no painful impression or sensation in the area or organ 
in which the pain originates. In other words, sympathetic pain 
is an overflow phenomenon, while transferred pain is due to con- 
veyance of the stimulus through collateral fibers from one cord 


segment to another which is either adjacent to or at a distance 
from it. As an example of sympathetic pain, we have the pain 
in the axilla passing down to the arm and hand, due to angina 
pectoris. The axilla, arm, hand, and heart are supplied by con- 
tiguous nerve roots, the third, second, and first dorsal (McKen- 
zie), and thus a stimulation of one segment is conveyed to the 
adjacent segment and the sensation is referred to the peripheral 
distribution of these segments. 

Pkojection Pain. — Closely allied to referred pain is projec- 
tion pain, a term given to pain which is felt as being present either 
in a part which has no sensation (as in locomotor ataxia), or in 
a part which, because of amputation, no longer exists. In the 
case of projection pain in an amputated limb, the pain seems 
to be due to the inclusion of the nerve in the cicatrix of the stump, 
or a neuritis, or a neuroma. It is also related in some way to 
the circulation. Otherwise how can the relief derived from eleva- 
tion of the stump be explained? Gordon (562) enters into the 
psychology of the subject to a considerable degree. Every con- 
ception of a limb is due to a visualization of the peripheral stim- 
uli which have been received. When irritation is present in the 
periphery of any amputated nerve, the visualization is still pres- 
ent, and from old association produces a picture of the absent 
limb. It is along this limb to the former distribution area of 
the various nerve fibers that the pain is referred. 

Gordon illustrates the visualization of an amputated arm, in 
which pain finally developed, in the case of "a railroader who 
met with an accident twenty-seven years previous, in which his 
left arm was crushed and amputated. Since the operation he has 
always felt the presence of the left arm. Soon pain developed, 
which was localized, mentally, so to speak, in the left limb. The 
severity of the pain gradually disappeared, though the pain itself 
did not cease. Upon examination, the stump appears to be cov- 
ered with a cicatrix. The latter is tender, and pressure upon it 
causes a sharp pain, which extends downward along the absent 
limb. The prick of a pin will also cause pain to be referred 
down the limb. If cold or hot water is applied to the stump, a 


sensation of cold or heat, respectively, will be felt bj the patient 
down the absent limb, as far as the tips of the imaginary fingers. 
He also has spontaneous sensations of the absent limb, and con- 
stantly feels the presence of the arm. He feels it hanging along- 
side of the body ; he feels the arrangement of the fingers and some- 
times their movements. There is a constant unpleasant feeling, 
a numbness in the absent limb. He also has at times a spontane- 
ous, sharp pain, of neuralgic character, which makes him flinch 
and double up. This pain, he says, runs through the ulnar side 
of the arm. A few months ago, the patient suffered an apoplectic 
seizure, following which a left hemiplegia developed. Since this 
cerebral disturbance, the former stump phenomenon became ag- 
gravated. The spontaneous pain in the absent arm is more fre- 
quent and intense, the numbness causes him more discomfort than 
previously, and finally the response to stimulation of the stump is 
decidedly greater." 

Reflected Pain. — The next variety of pain which we shall 
consider under reflected (deflected) pain is that in which the stim- 
ulus is carried to the sensory ganglia or to the cord and then trans- 
ferred from the sensory filaments of the neuron primarily affected 
to those of a secondary neuron. The stimulus is then carried, in 
this neuronic pathway, to the brain, and is perceived' as coming 
from the distribution area of the second neuron. This variety of 
pain differs from referred pain in that in reflected pain there is a 
transfer of painful stimuli from one neuronic system to another, 
while in referred pain there is no transfer but only a misreference 
of the pain by the sensorium. A better term to express the true 
characteristic of this variety of pain would be "deflected," instead 
of "reflected" or "reflex." "Deflect" means to turn aside, or to 
shunt, while "reflex" means to turn back; and, since the pain is 
not turned back, but is only swerved into another pathway, it 
seems that "deflection" would characterize the change more than 
would "reflection." Besides, in physiology "reflection" is gener- 
ally used to indicate a reaction produced in some portion of the 
body by a change in another part ; and for this reaction "afferent 
and efferent fibers are necessary. The former are of a necessity 


sensory; the latter may be motor, vasomotor, vasoinhibitory, car- 
dioinhibitory, or secretory. They are never sensory, for the simple 
reason that a sensory nerve is always afferent, and there can be 
no reflection without descending fibers" (Hart, 273, p. 344), so 
that it would seem to be better to use deflection instead of reflec- 
tion. These deflections probably have an anatomical basis. Re- 
cent researches show that the nerve cells (in a segment) of the 
cord undergo degeneration as a result of any lesion in the corre- 
sponding segmental distribution area (Lickley, 138, p. 438). 
This confirms the hypothesis that stimuli causing pain arise from 
direct irritation from pathological changes in the cord, and are not 
due simply to a transfer of stimuli from one set of cells to another. 
The most numerous and important of reflected (deflected) 
pains are those due to pathological changes in the internal viscera. 
The viscera of themselves have no sensation of pain, as elicited 
by ordinary pain-producing stimuli. They can be cut, torn and 
sutured without the production of pain ; likewise, they are insensi- 
tive to heat and cold, but have a sense of their own which tells 
the sensorium of their well-being with a sensation akin to that 
which we term muscle-sense, or joint-sense. When the viscera are 
irritated, the stimuli are carried to the cord and react on the cord 
cells; and impulses are produced and sent out as motor impulses, 
or are carried to the brain by the neurons of these cells, where 
they are perceived as painful. At the same time, the adjacent set 
of cells become irritable, and react abnormally to all stimuli reach- 
ing them from the periphery. Thus, we have the origin of the 
hyperalgesic zones of Head. These zones are not always present 
over the area of the involved viscera, and the reason for this, as 
given by McKenzie, is that in the course of development the tis- 
sues, which in a low form of life must immediately have covered 
the organ, became displaced. In this way, several peculiarities of 
pain-production may be explained. For instance, the pain in the 
testicle in ureteral colic is felt, because, in early fetal life, the 
testicle was very high in the abdomen, and was supplied by the 
first lumbar segment. Then it began to journey through the ab- 
dominal ring and into the scrotum ; but it always retained its 


nerve supply. The ureter, likewise, receives its nerve supply from 
the same segment, so that when irritation occurs in the ureter the 
pain is often referred to, and is felt as arising in the testicle, 
which at the same time is tender. In renal colic the skin of the 
scrotum is never hyperalgesic, because the scrotum is supplied by 
the sacral nerves ; but the deep coverings of the testicle are always 
hyperalgesic, because they are in relation with the same cord seg- 
ment as the kidney (McKenzie). 

The method of localizing the viscus causing the reflected pain 
is given below: 

(1) Determine if, in connection with it, there is an asso- 

ciated area of hyperalgesia. 

(2) Delimit the area of hyperalgesia as nearly as possible, 

and orient it with a cord segment. 

(3) Find out what organs are supplied by this segment. 

(4) Examine the organ or organs for disease, 

(5) See if the pain can be reproduced by manipulation of 

the organ. 

The general lowering of the vitality of a patient often aids in 
the production of reflected pains by reducing the resistance and 
increasing the irritability of the affected cord segment.-^ 

Sometimes reflected, referred, or transferred pains are con- 
fused with neuralgia ; from this they can be differentiated by the 
injection of cocain, which will ease the pain of a neuralgia, but 
will have no effect on referred pain. 

Transferred Pain. — Transferred pain is the name given to 
that variety in which the stimulus passes from the neuron in which 
it is originally present, over an intermediate neuron, to a third 
neuron, in the area of distribution of which it is perceived as 
being present. 

In other cases the sensorium may mistake the peripheral dis- 
tribution of the pain, as in degeneration of the posterior roots 
(tabes), or of the ganglia and posterior columns, or cornu of the 

' For a more complete exposition of this subject, see under Head's Zones, 
Visceral Sensibility. 


cord. It is very likely that in certain conditions the sensory im- 
pnlses which are carried by the sensory fibers and the gray matter 
are not entirely obtnnded or destroyed by the pathologic processes 
which have taken place, so that touch can be conveyed to a minor 
degree, and localizing sensations, such as those which tell us of the 
position of a limb, may be present only in a very restrictive sense. 
Therefore, an impulse propagated through the sensory pathways 
is very weak, and on its perception by the brain (there being little 
or no localizing stimulus accompanying it), is perceived as coming 
from the opposite side where the localizing neurons are intact. 

When the transference occurs in the cord, the segment affected 
may be homologous to the segment in whose area the impulse was 
originally received, or it may be higher, or it may be lower. In 
the latter cases the impulse is transmitted to the perceptive (third) 
neuron through some of the collateral branches. 

Examples of pain transferred to a homologous segment in the 
same relative position on the opposite side of the abdomen are 
found in appendiceal and ovarian diseases, pneumonia, and 
pleurisy. Examples of higher and lower reference are found in 
those cases in which the pain of pneumonia is transferred to the 
appendiceal region, or in which the appendix causes pain which 
is transferred to the thorax. Mitchell (559) cites two instances 
of this variety of pain. In the first case a window fell on a finger 
upon which there was a felon. The pain was felt in the finger, 
and at the same time in the face and neck on the opposite side 
of the body. The second case is that of a patient who had a heavy 
weight fall upon his right foot, striking the toes. The great toe 
and the one next to it were injured. Immediately pain was felt 
on the antero-internal aspect of the opposite leg, at the junction 
of the upper and middle thirds. The pain was of a burning char- 
acter, fairly constant, and worse at night. It persisted for three 
weeks longer than the pain in the injured part. The case has also 
been cited of pain in the left thumb caused by a felon on the right 
tliiinib. In another instance a wound on the right side of the 
neck caused paralysis and pain in the left arm (Mitchell, 559). 
Mitchell also mentions a case in which a shell woimd in the right 


leg caused the patient to complain of a burning pain in both, the 
left and the right arm and in the right pectoral region. 

In regard to the cause for the persistence of these pains, I shall 
quote from Dr. Mitchell (559), who says that "one can, in a meas- 
ure, comprehend that a violent stimulus to a sensory nerve can be 
switched off on to other nerve tracks or centers, as if it were the 
escape of an overcharge ; but even if we hazard such a hypothesis, 
it is still difficult to explain the persistency of these transferred 
impressions, for it is a law of the receiving centers for painful 
impressions that when the cause of the pain ceases to be active 
the feeling of being hurt ends. But in some of these examples 
of false reference of pain there must have been made in the center 
some more or less permanent change that continuously represents 
the eifect to which any pain-producing agency usually gives rise." 

I have noticed that pain is more likely to be referred to the 
opposite side from that on which the lesion is located, in elderly, 
unmarried females. What, if any, bearing their social state has 
upon this fact I am unable to say. 

Character of the Pain. — Another classification of pain is that 
founded upon the description furnished by the patient. This is 
most varied. A patient with a lively imagination can, of course, 
give a more vivid description of pain than those of a somewhat 
duller mentality. K^aturally, the pain is likened to some sensa- 
tion which has been experienced in the past ; hence the terms : 
burning, gnawing, cutting, pinching, smarting, lancinating, bor- 
ing, shooting, screwing, gripping, stabbing, grinding, sharp, dull, 
aching, lightning, tearing, creeping, throbbing. 

In earlier times this method, founded on the description of 
the patient, was the one usually employed ; and, with the tendency 
of the age to scholasticism, pains were elaborated and defined until 
a celebrated physician of the time of Trajan recognized thirteen 
varieties, and, not to be outdone, Halmeman, another early physi- 
cian, distinguished seventy-five. Avicenna, in the tenth century, 
A. D., wrote a work on medicine, in which, among other matters, 
he distinguished fifteen varieties of pain (Allen, 563). 

This method of classification, however, proves very unreliable. 


because of the difference in susceptibility of different people, and 
of their varied powers of expression. Yet, it is of some value in 
diagnosis, for certain pains, as described by the patient, are 
characteristic of certain disease (Church and Peterson, p. 960), 
as the lightning pain in tabes, the gnawing pain in rheumatism, 
the burning pain in neuritis, the girdle pain in spinal disease, the 
lead-cap pressure pain in neurasthenia, the sharp, cutting pain in 
neuralgia, and the dull, aching pain in infectious diseases. 

Persistency of Pain.-:— Pain is divided, according to persist- 
ency, into constant, intermittent and remittent. Each of these 
may again be divided, according to the subjective feeling, into 
dull, aching, etc. Likewise each may be classed under some 
variety of the anatomical divisions of pain, as referred or re- 
flected. When a pain is constant, it is necessary to investigate 
those conditions which act constantly and which produce pain. 
Among the most common causes of constant pain are new growths 
pressing upon the nerve fibers somewhere in their course. This 
pain is referred to the peripheral distribution of the affected fibers. 
Should the pressure be produced by an inflammatory mass, the 
pain is constant, but is marked by periods of lessened severity. 
These periods indicate the intervals in which the inflammatory 
congestion is diminished. In other cases the remission may be 
complete, and the patient may be free for a shorter or longer inter- 
val, as happens in salpingitis and oophoritis, in which frequently 
the pain is absent during the intermenstrual periods, and reap- 
pears when the menstrual congestion occurs and the blood pres- 
sure and internal congestion in the affected organs are again 

Under certain conditions, pain may occur in paroxysmal at- 
tacks of great severity, to which the term crises has been given. 
According to Fenwick, who -quotes from H. C. Moore, a pain crisis 
consists of a paroxysm of pain as violent as human nature can 
endure, accompanied by excessive functional activity of the part 
attacked, but disappearing as rapidly as it appeared, and is asso- 
ciated with a condition of undisturbed functional activity of the 
affected viscera between the paroxysms (Fenwick, 569). 


Time of the Pain. — Pain may be further divided into diurnal 
and 7ioctumal. Diurnal pains are worse in all those condi- 
tions which are aggravated by activity, either mental or physical. 
For this reason neurasthenics and those afflicted with diseases of 
the locomotor apparatus suffer more during the daytime. Such 
conditions are found in rheumatism, neuralgias (as sciatica), flat 
foot, joint disease, etc. Pain is also greater during the day in 
eye-strain and diseases of the eye, and also, as a rule, in diseases 
of the gastrointestinal tract. This is due, in both cases, to the fact 
that during this time the organs are most active. Yet, as a rule, 
it seems that nocturnal pain is more frequent than diurnal pain. 
When pain is present during both periods, it is more severe at 
night, because during the day the mind has so many other affairs 
to occupy its attention that it does not perceive the pain sensations 
as acutely as it would if it were free of other impressions. At 
night everything is quiet, the other senses are in abeyance, and the 
pain-sensation enters and alone occupies the mentality. 

Among pains which are prominent at night are those due to 
syphilis, uremia and gout. Schmidt (564, p. 68), in speaking of 
these conditions, says : "It seems that, as a result of the diminu- 
tion of the metabolic function, through the absence of muscular 
work, there is a decrease in respiratory and cutaneous activity. 
Therefore, when a dyscrasia exists, the toxic curve ascends at night 
and leads to nocturnal attacks of pain. The pain of tuberculous 
hip-disease is also most pronounced during the night. In this 
disease when night comes on and the patient is asleep he often 
cries aloud and awakens complaining bitterly of the pain in his 
hip. It is claimed that the pain is due to a relaxation followed by 
a sudden contraction of the muscles around the joint. During the 
day they are contracted and hold the limb in such a position that 
the least possible injury can be done to it. During the night these 
muscles relax and the limb falls away until slight pain results. 
Then the muscles sharply contract and draw it again to the posi- 
tion of least pain; but as they do so, they also throw the head of 
the bone forcibly into contact with the acetabulum, and thus cause 
the sudden, sharp, acute pain, of which the patieut so complains." 


Colics are also most pronounced during the night. Schmidt 
(564, p. 64) says: '^It seems that a relationship exists between 
smooth muscle fibers and striped ones, so that when one set is 
active the other is idle. During the day the striped muscle fibers 
are active, and, as a consequence, the smooth ones are idle, while 
the smooth ones become active during the night, when the striped 
ones are idle." 

Gall-stone and appendicitis pains are frequently present at 
night, many hours after the ingestion of food. (For fuller dis- 
cussion, see Gall Stones and Appendix.) 

When a patient gives a history of pain occurring at particular 
times one should inquire as to his habits of life, what his routine 
of w'ork is, how and when he eats, and if the pain seems to be asso- 
ciated with the ingestion of food. If it does, one should ascertain 
if it follows the ingestion of all varieties of food, or only certain 
varieties, and inquire whether the pain is relieved by the ingestion 
of food. Hunger headaches and hyperacidity pains in the stomach 
areas and pains of duodenal ulcer are eased by the taking of food, 
particularly albuminous foods. 

In some cases the pain-sensation travels more slowly than is 
normal, the so-called delayed pain. In these the touch-sensation 
is present some time previous to the pain-perception. Tabes dor- 
salis gives such a pain-reaction. It may be observed by pricking 
the patient with a pin and having him say "ISTow" when he per- 
ceives the sensation of touch, and "Oh" Avhen the sensation is pain- 
ful. He will say "ISTow" much earlier than "Oh," showing that 
the pain-perception is delayed. It is hardly possible that the 
delay occurs in the transmission, for it seems that all impulses 
travel along the nerve with equal speed ; yet, such is the explana- 
tion given by Landois ("Physiology," p. 936, American trans- 
lation, 1904). 

Sensitiveness to Pain. — It seems that sensibility to painful 
impressions is present in early infancy, but is not as acute as in 
later life. The infant, at the time of its birth, I have no doubt, 
is able to receive the impressions which later it interprets as 
painful ; but it requires time to learn to coordinate the sensory 


impressions and classify them as beneficent or harmfiTl, so that at 
this early age pain-perception has not as yet entered into its con- 
sciousness. We may say that the infant has an instinctive dread 
of all sensations which betoken an act or condition detrimental 
to its welfare. This protective and defensive instinct is an in- 
herent and non-cognitive factor in its development, arising not 
from previous experiences, but from some inlierited and latent 
consciousness which awakes under the stimulus of external life 
and takes upon itself the defense of the organism through the 
perception of all pernicious impulses as disagTeeable sensations 
(principally as pain) from which it is wise to be dissociated. As 
the infant develops, it becomes more sensitive to all painful im- 
pressions until, in adult life, it probably has reached the acme 
of sensitiveness. From this period until middle age the perceptive 
powers probably are stationary. Then, as age advances, they 
«gain become reduced, until in old age they are once again at a 
minimum. As the ability to withstand pain differs at different 
ages, it also differs among races and individuals of the same race. 
Among races, it is claimed that the Hebrew stands pain less easily 
than any other race (Editorial, British Medical Journal, April 
14, 1906, p. 880). Such general statements, however, smack of 
the feuilletonist and are not to be taken too seriously. 

Individual Susceptibility. — Among individuals, the ability to 
withstand pain varies markedly. It seems that those of a fair 
and very delicate skin are most susceptible. In these people the 
pain-receptors, because of the lack of protection which is given by 
a thick epidermis, are more exposed and possibly more subject to 
irritation than in those of a thicker integument. Such people are 
not only very susceptible to pain, but also to cutaneous irritability 
of any kind. Others, because of lack of mental development, are 
incapable of acute perception of pain ; while still others, because 
of intense will power, or of some inherent inability to perceive 
pain, are comparatively immune. Bennett mentions such a case 
of stoical disregard for pain. A celebrated French surgeon was 
performing an amputation, and, seeing the look of distress on 
the face of the jDatient, said: '^I fear I am causing you great 


pain," to which the patient replied : "Xo, the pain is nothing ; 
but the noise of the saw sets my teeth on edge." 

Ottolenghi (449), who made records of cases of six hundred 
and eightv-two women, found that women were less sensitive than 
men, and draws the following conclusions in regard to pain in 
women at different ages. He states that the sensitiveness is less 
in earlj life, increases to the twenty-fourth year, and then de- 
creases. This sensitiveness is greatest in the nineteenth year. 
The higher the type, the greater the sensibility. The left temple 
and left hand are more sensitive than the right. Luxury seems 
to increase susceptibility to pain-perception. The divisions of 
womanhood, in order of susceptibility to pain, are : ( 1 ) girls of 
wealthy classes; (2) self-educated women; (3) business women; 
(4) university women; and (5) washerwomen. .We have here a 
generalization whicb must be taken "cum gTano salis." 

Tissue Susceptibility. — Tissues vary in susceptibility to pain. 
Metziuger (328, p. 141) claims that the blood supply of an organ 
often determines its sensitiveness to pain, as the organs whick are 
the richest in blood supjDly generally suffer the greatest pain, and 
that organs poor in blood supply have little, if any, pain. This is 
in accordance with the theory of Oppenheimer, who claims that 
the pain is created and carried by the vasomotor system. As ex- 
amples of the effect of blood supply, he cites the lack of pain in 
cartilage, nails, and hair, and the slight pain in pneumonia, while 
pain is present to an enormous degree in the periosteum, perimy- 
sium, pleura, peritoneum, etc. He gives bone as an example of a 
tissue which is free from pain,^ but he says that this is due to the 
fact that when blood-vessels enter the compact structure of the 
bone they discard their muscular coat and so lose the vasomotor 
nerves and the pain sense. These sympathetic vasomotor fibers 
are supposed to issue by tke post root, with the sensory fibers, and 
enter the spinal ganglia. In the cord they can be traced to the 
antero-lateral ascending tract. Some fibers pass to the anterior 
horn, and still others to higher or lower ganglion cells. 

1 In recent experiments we have found that the medullary cavity of bone 
is very sensitive. 



It is always interesting, and in some cases it is important 
for the diagnosis, to know the intensity of the pain suffered by 
the patient. The patient should always be interrogated, there- 
fore, regarding this point. Very often the answer is of consid- 
erable importance in enabling the clinician to make a diagnosis ; 
but when the physician takes the word of the patient he is apt 
to be misled, perhaps not intentionally, yet misled, nevertheless, 
because in the great anxiety of the patient to give a proper im- 
portance to his complaints, he is apt to magnify his symptoms. 
However, there are certain means of checking the patient's state- 
ments so that it may be ascertained whether or not he is speaking 
the truth. 


Before going into details concerning these means, we must first 
study the factors upon which the intensity of pain depends. These 
factors are: (1) the stimulus; (2) the sensitiveness of the 
patient; (3) the irritability of the nerves; and (4) the extent and 
number of the nerves involved. 

The Stimulus. — The stimuli may be of different degrees and 
strength, and they may be exerted continuously or intermittently. 
A stimulus that is exerted continuously will be felt, at first, as 
much more severe than one of equal force which is not so exerted. 
As the stimulus continues, the reaction becomes weaker, until the 
perception center is dulled and does not react at all. Likewise, 
a constant stimulus alternately weak and strong will be more pain- 


fill than one which is constant, but of equal force. The reason for 
this is that when the stimulus is constant, either the conducting or 
the perceptive apparatus becomes fatigued, and the stimulus is not 
perceived as acutely as when intermissions take place, since during 
these intermissions the nerves have time to recover their sensitive- 

Sensitiveness of the Patient. — Susceptibility to pain varies 
among different individuals. Some react to a painful stimulus 
much more readily than do others. My experience has shown 
that those of a thin and neurotic build suiler much more severely 
than do the heavier and more robust. There seems, also, to be a 
certain relationship between the degree of mentality and suscep- 
tibility to pain. The higher the development and the more vivid 
the imagination, the greater is the susceptibility. Those who are 
not particularly affected by pain or emotion we call phlegmatic. 
All their sensibilities seem dulled and inactive. 

Irritability of the Nerves. — The trigeminus, the sciatic, and, 
it is said, the splanchnic nerves are, as compared with others, ex- 
tremely irritable. 

Extent and Number of Nerve Fibers Involved. — The severity 
of the pain depends upon the number of fibers which are involved. 
The greater the number of fibers the more intense the pain. 


The factors modifying pain production are psychical and 

Psychical Factors. — The psychical factors may be divided 
again into emotion, consciousness, suggestion, diversion of atten- 
tion, and expectation of pain. 

Emotions greatly modify pain-sensation. For instance, vio- 
lent anger or great joy preempts the sensorium to such an extent 
that sense-perception is dulled and may become absolutely nega- 
tive. Consciousness, of course, is necessary for the perception of 
pain, and the more acute the consciousness the greater the pain. 
Those who are worn out with physical work will often suffer less 


from an injury tlian their more vigorous fellow-workers. Sugges- 
tion is also of considerable importance in pain phenomena. Many 
modern cults have made capital out of the fact that pain may 
often be eased by concentration upon some other object, or by self- 
persuasion (auto-suggestion) that pain is not present. Yet this is 
not new, for physicians have made use of this principle even as 
far back as the time of Pharaoh. Diversion of attention is im- 
portant, for the reason that when a patient's attention is drawn 
to some object, and is entirely engrossed with it, he has two cen- 
ters (sensory) which are active, as a consequence of which neither 
is apt to be as sensitive as if acting alone. 

Physical Factors. — Physical factors influencing pain may be 
divided into the intrinsic and the extrinsic. Among the intrinsic 
factors are digestion, motion, urination, defecation, menstrua- 
tion, respiration, and position of the body. Among the extrinsic 
factors are pressure, heat, cold, electricity, and drugs. 

Intrinsic. — Digestion, as a rule, causes pain only when dis- 
ease of the alimentary tract or some of its related organs is pres- 
ent. The severity of the pain depends upon the kind of food 
taken, and the variety of the lesion. In all cases indigestible 
food increases the pain. When the pain comes on immediately 
after eating, one would naturally think of gastric ulcer ; if in an 
hour or two, of duodenal ulcer; and if in three or four hours, of 
gall-bladder or common duct disease. Also, at about the same 
interval pain due to appendiceal or colonic diseases makes its 
appearance, although that from colonic disease generally occurs 
somewhat later, say in five or six hours. Should the entrance of 
food into the stomach ease the pain, carcinoma, duodenal ulcer, or 
a pure neurosis is probably present (Schmidt). Should the pain 
come on during the ingestion of food, it indicates some disturb- 
ance in the esophagus, such as ulcer, stenosis, or a lesion at the 
cardiac entrance to the stomach, such as cardiospasm. 

In all inflammatory states, when motion causes pressure to be 
made upon the inflamed area, pain results. When a patient com- 
plains of pain upon moving a part, careful investigation should 
be made of the muscles, bones, joints, and nerves composing that 


part. In connection with the muscles the most common painful 
affections are inflammations, as niyelitis or abscesses. In some 
cases, while the lesion is not in the muscle itself, it is adjacent 
thereto, and contraction of the muscle will produce traction and 
pressure upon the inflamed area. Such a condition is found fre- 
quently in appendicitis. The appendix lies over and is joined to 
the psoas, so that each time the limb is flexed, and the psoas con- 
tracted, pulling and traction on the inflamed tissues occur, and 
pain is felt. Therefore, whenever pain is complained of in 
connection with muscular movement, not only the muscle but all 
of its adjacent and related structures should be investigated. 
Should the muscle prove negative the bone may give some infor- 
mation as to the cause of the pain. In this direction the first 
line of inquiry will be as to the condition of the periosteum, and 
if it is found to be healthy, the bone may be excluded as a 
cause of the pain. After careful investigation of these structures, 
the joints should be examined, and flexion and extension tried. 
Especially in disease of the articular cartilages pressure made 
by forcibly pressing the two articular surfaces against each other 
is provocative of the greatest pain. 

Pain may be caused by change of position. This occurs espe- 
cially in those organs which are held in position by "ligaments and 
end attachments, such as the stomach." Here a change of posi- 
tion produces a disturbance of their relationship to surrounding 
organs, and in some cases a derangement of their functional 
economy. It may produce, also, pressure or traction on an in- 
flamed area. All of these factors lead to an increased amount 
of irritation and pain. The occurrence of a painful lesion upon 
a change of position of the patient indicates a local disorder. 
Certain positions are characteristic of certain classes of disease 
(see Positions of Pain). 

Pain associated with defecation occurs at the time of the 
movement, or a little later. If it occurs at the time of the move- 
ment one would naturally think of some lesion involving the 
sphincter or the anus. Of these, inflammation, from simple in- 
filtration to abscess formation, is very painful. As much so, or 


even more painful, is fissure or ulcer of the anus. When the 
pain persists for some time after defecation an abscess may be 
present. Pain coming on immediately before the act indicates 
deep-seated ulceration, such as would occur in carcinoma of the 
rectum (Schmidt, p. 42). Abdominal pain, the result of strain- 
ing accompanying bowel movement, may indicate some quiescent 
inflammatory process in the appendix or the gall-bladder. By 
constipation the pain of enteroptosis, intestinal atony and neu- 
ropathic conditions is retarded. 

Extrinsic. — Of the extrinsic physical factors modifying pain, 
pressure is by far the most important. In many instances it is 
the underlying factor of pain-production. Structures are so 
joined and related to each other that pressure is constantly ex- 
erted by the one uj^on the other, and any disarrangement of this 
adjustment may cause the pressure to become excessive, and re- 
sult in pain. 

Electricity causes pain by stimulating the pain receptors. The 
pain may also be due in part to muscular contraction and to sud- 
den changes in the relationships of the parts, caused by opening 
or closing of the circuit. The faradic current is probably the 
most painful. The static spark is also quite painful. 

Extremes of heat and cold both cause pain, and, most pecu- 
liarly, the sensations caused by excessive degrees of either are 
almost identical. Thus it is that one speaks of the burn due to 
excessive cold. In case of pain due to freezing of a part addi- 
tional pain is produced by placing the hand in hot water, which 
is due to the dilatation of the vessels and engorgement of the 
tissues of the part. This engorgement increases the pressure 
upon the pressure-pain receptors, and thus causes an increase of 
pain. Cold acts in an opposite manner. It causes contraction 
of the vessels and a lessened blood supply in the part. Metabolism 
is interfered with, and toxic products^ accumulate in the tissues. 
These act upon the sensory receptors in the part and cause pain 
in addition to that caused by the action of cold upon the cold pain 

1 Toxic products also in some cases produce anesthesia. See under 


receptors. In either of these cases the pain is due to the stimula- 
tion of the temperature receptors, plus the stimulation of the 
deep sensibility receptors. In some cases of heat pain, for a short 
time two different sensations are felt, one being that of heat, 
and the other that of pain. Then the sensation of heat disappears 
and only that of pain persists. The only reason that both cannot 
continue is that the pain sensation soon becomes paramount, and 
preempts the sensorium. Another argument in favor of the sepa- 
rate origin of temperature sensation and of pain sensation from 
excessive degrees of heat or cold is that pain may be present from 
hyperstimulation of either, in the absence of temperature sense. 
That is, excessive degrees of heat or cold produce pain, while 
moderate degrees of either cannot be recognized, or, if they are, 
the one is confused with the other. 

Drugs modify pain by various means. They usually block 
the carrying power of the nerves peripherally (morphin or co- 
cain) or centrally (morphin or ether). They may create changes 
in the organs in which pain arises, and thus cause changes in the 
pain. For instance, alkalies reduce the acidity of the stomach and 
decrease the pain caused by a hyperacidity. Mercury and the 
iodids frequently relieve pain due to syphilis. On the other hand, 
tuberculin increases the pain, if it is due to tuberculosis (Schmidt, 
p. 40). Emptying the bowels relieves certain headaches. The 
withdrawal of morphin, in the case of a person who is accustomed 
to its use, very frequently causes great pain. 

Weather. — Pain also seems to be influenced by' temperature 
changes, for it has been observed that a lessened barometric pres- 
sure causes a weakened resistance to pain. Evertt (566), from 
a study of a number of cases, found the period of greatest pain 
to be from nine to eleven a. m. A period of less severe suffering 
is between eight and ten a. m. Barometric changes influence 
the production of pain much more than does the actual presence 
of storms. Damp, musty weather also influences pain production 
(Head and Rivers, 201, p. 54). Evertt believes that the cause of 
this increase in pain is that the electricity in the air, is increased 
during these periods of atmospheric unrest. 



It is necessary, not only to know that a person has pain, bnt 
also how to estimate and measure its intensity. This knowledge 
is important in order to check the many misunderstandings that 
occur, sometimes intentionally, sometimes unconsciously, between 
the physician and his patient. It is also of value occasionally, in 
deciding upon the progress of a disease. The different means of 
measuring the intensity of pain are: (1) blood-pressure eleva- 
tion; (2) motor reflexes; (3) complaints of the patient, com- 
pared with his ability to withstand pain; (4) reflex vasomotor 
signs, as syncope; (5) dilatation of the pupil; (6) amount of 
morphin necessary to overcome the pain; (7) appearance of the 
patient; (8) patient's description of the pain, and (9) mechanical 

Blood-pressure Elevation. — Blood-pressure elevation is an im- 
portant means of estimating the intensity of a pain. Studies 
along this line have been made, particularly in Germany, where 
the question of simulation is so important, because of indus- 
trial insurance. Curschman (567) found that in eighteen out of 
twenty people with normal sensibility the blood pressure rose 
eight or ten mm. of mercury under stimulation with a f aradic cur- 
rent (on the upper part of the thigh). In the other two persons 
the rise was somewhat higher (ten to fifteen mm.). In nine cases 
of hysteria and in five cases of disease of the spinal cord, the pres- 
sure was unaffected. During the gastric and intestinal crises of 
tabes, and in lead colic, a pressure of 170 to 210 is common, but 
quickly subsides to normal, 115 or 120 mm., when the attack is 
over. In other painful abdominal affections only a very moderate 
increase in pressure, ten mm., occurred. Janeway reports the 
following cases: (1) A woman of twenty-eight, with a blood 
pressure of 70-80 mm. between the paroxysms of pain, had 170 to 
190 mm. in moderate and 240 mm. in very severe attacks. (2) 
A man thirty years old had a blood pressure of 65 mm. between 
paroxysms and of 140 mm. during the paroxysms. The climax 
of hypertension and pain seemed to coincide, and both passed 


away together. Morphin caused sleep and a lessening of the pain, 
but no fall in pressure. Chloral caused a hypotensive, as well as 
an analgesic, effect. 

"Of special interest (again to quote Janeway's words) was the 
alternation of the abdominal and the lancinating pains. When the 
latter came on, the pressure promptly fell, and the visceral crises 
ceased. Therefore, Pal assumes that a spasm of the splanchnic 
vessels is the cause of pain in a gastric crisis, and that the irrita- 
tion which causes the lancinating pains affects depressor fibers 
in the posterior roots, and the stimulus is sufficient to interrupt 
or cut short an abdominal crisis" (Janeway, 568, p. 247). 

In this connection it is of value to know that, an arterioscler- 
otic condition of the abdominal arteries will at times, when the 
pressure is high, cause a dull, aching pain in the abdomen. This 
increase in the blood pressure is due to the stimulation of the vaso- 
motor nerves (the vasoconstrictor part), and is produced princi- 
pally in the splanchnic area. During labor pains, also, the blood 
pressure is raised. Coincident with each pain it becomes higher, 
and varies directly as the pain. As labor continues there is a 
constant increase in pressure until the child is expelled, when 
there is a drop to a point slightly below normal. This increase of 
blood pressure is not due to the psychic influence of pain, for it is 
present even when the jDatient is unconscious from the administra- 
tion of an anesthetic. It may be due to the following causes: 
(a) uterine contractions; (b) muscular contractions of the abdomi- 
nal wall, causing an emptying of the splanchnics and a consequent 
increase of the peripheral pressure; (c) excitement when the 
patient is conscious. Worry may also have influence. It seems 
hardly reasonable to suppose that the small increase in the quan- 
tity of blood thrown into circulation at each contraction of the 
uterus would be sufficient (when we consider the great adapta- 
bility of the circulatory system to accommodate great or sudden 
increases in the amount of circulation fluid) to cause any appre- 
ciable increase in the systolic blood pressure ; though the asso- 
ciated contraction of the abdominal muscles, and, in fact, of 
nearly all of the musculature of the body, it is reasonable to 


suppose, will produce a gTeat elevation of blood pressure. We 
must bear in mind, also, tbe fine supply of sympathetic nerve 
fibers to the uterus and adnexa. After all, the increased vascular 
tone is, in all probability, due to this elaborate nerve supply and 
its irritation. 

Motor Reflexes. — The reflexes produced by pain are protective 
in their tendency, in that they are a means of defense instituted 
by nature against injury. In every instance, if possible, they 
tend to remove the organism from the source of danger. They 
are very active and are constantly exerted. For instance, when 
the hand comes in" contact with a heated object, it is immediately 
drawn away by a quick, automatic muscular movement, even be- 
fore the individual becomes aware of thfe contact. In sleep many 
reflexes are active, and in some diseases of the cord (transverse 
myelitis) they may be present even when pain sensation is absent. 
Even in light anesthesia, this reflex-protective action is present, 
as is seen in abdominal operations when the parietal peritoneum 
is somewhat roughly handled. Although sensation is not present, 
the reflexes are, and, acting immediately, produce such a sudden, 
strong contraction of the abdominal muscles, that it is almost im- 
possible for the surgeon to do his work. The defensive power of 
the reflexes is best exemplified in consciousness when the patient is 
under the influence of pain. The centers for voluntary muscles 
are thrown into activity, so that the organs, the seat of deleterious 
changes, may be protected from injury. Every physician is aware 
of the rigid contraction of the abdominal muscles in pelvic or peri- 
toneal disease, and of the extent to which the administration of 
an anesthetic simplifies and renders easy a manual examination. 
Can anyone doubt that the higher automatisms, with appreciation 
of pain, are active in causing this rigidity ? Almost innumer- 
able examples of the same kind might be cited, for instance, the 
contraction of the muscles surrounding a joint, and its consequent 
fixation, in those cases in which articular inflammatory states are 
present, or the rigidity of the head in disease of the soft struc- 
tures at the base of the skull in meningitis, etc. 

In view of the universality of these defensive reflexes, it is 


jfitting that we should be a little curious as to the reason for their 
presence. We know that nature is always purposeful. Every 
act is conservative, and we may be sure that when pain, with 
its attending reflexes, is present, there is a good reason for its 
appearance. This reason is protection against further injury. 
For this purpose are called into play the only reflex organs m 
the body capable of resistance, namely, the muscles. As a result 
of their stimulation and consequent contraction either rigidity or 
motion, or both, follow. Rigidity is best seen in the cases of 
abdominal diseases above mentioned; motion is best illustrated 
by the quick withdrawal of* the hand from a source of injury. 

Two of the special senses, taste and smell, owing to their func- 
tions, have developed a special sensation which is termed nausea. 
It is of a disagreeable, sickening nature ; and finally, if suffi- 
ciently prolonged, causes a protective reflex action in the 
form of vomiting. This reflex, as one would judge from its inti- 
mate dependence upon the sympathetic system, is practically an 
involuntary act, though sometimes it can be produced by conjuring 
up in the mind pictures of disagreeable or disgusting objects. 

Hearing, also, is somewhat different from the other senses. 
Here an excessive stimulant gives rise to a sensation, which, if it 
cannot be accurately classified as pain, is closely akin to it, be- 
cause of its intensely disagreeable nature. When this sensation 
is present, protection from the causative agents (noises, etc.) is 
sought by placing the hands over the ears, so that the distressing 
sounds may not enter. 

All of these reflexes are accompanied by certain well-marked 
and clearly defined changes in other systems, as the circulatory, 
digestive and pulmonary systems. 

Complaints of Patient Compared with His Susceptibility. — 
A comparison of the complaints of the patient with his ability to 
withstand pain often gives an indication of the severity of the 
pain. This ability varies in different people. Some, especially 
those of a phlegmatic temperament, seem to be capable of bearing 
pain of much greater intensity than those of a nervous, active 
nature. Blondes, also, seem to be more sensitive than brunettes. 


Personal idiosyncrasies, however, are of great value in estimating 
the severity of pain. 

To determine the sensibility of the patient, the skin on an im- 
aifected part of the body should be pinched between the fingers. 
When the abdomen is not affected, it is best, because of its great 
sensitiveness, to use it as a control. By the response to various 
degrees of pressure, an estimation can often be made of the 
susceptibility of the patient. 

Vasomotor Signs.' — Vasomotor signs, as pallor and syncope, 
often give an indication of the severity of the pain. These 
changes are due to a reaction of the pain stimuli upon the vaso- 
motor system, and it is necessary to inquire into their cause. 
The vasomotor system consists of centers to which two sets of 
fi.bers are connected, namely, the inhibitory fibers and the con- 
strictor fibers. The inhibitory fibers convey impulses which hin- 
der the contraction, and the constrictor fibers convey impulses 
which stimulate the contraction of the muscular coat of the blood- 
vessels. It is very difficult to say in what way mental states have 
an action on the physical processes of the body; but that they 
have is evident, and that the action is a powerful one can be 
seen from the persistence of the induced physical changes. How 
the vasomotors are influenced it is very difficult to say. Yet we 
know that they may be influenced by many mental processes. 
For instance, pallor is induced by fear, fatigue, nausea, or severe 
pain. Redness is induced, in the process called blushing, either 
by a stimulation of the vasomotor inhibitory fibers or by a 
paralysis of the contracting fibers, producing a paralysis and 
dilatation of the blood-vessels of the face and neck. The vaso- 
motor fibers pass up the cord in the lateral tracts, and pain sen- 
sation is also conveyed by the lateral tracts; so it can easily be 
seen how any change in the fibers conveying pain sensation would 
react on the vasomotor fibers and produce changes in them. 

Pallor and syncope may be the indication of shock due to 
intense irritation of the sensory terminal filaments. According 
to Henderson, this shock is the result of the rapid respiration al- 
ways induced by peripheral sensory irritation. In his experiments 


consciousness was abolished by the use of ether and morphin, so 
that the results were not due to consciousness of suffering, but to 
nerve irritation. It seems that consciousness of suffering is a 
mere accompaniment and not a causal element in the production 
of shock, which is of a reflex nature. Among other signs of shock 
are rapid and feeble pulse, vomiting, drawn, anxious features, 
and excessive perspiration. The susceptibility to shock varies. 
In those of a well-marked nervous temperament shock from a 
small injury is greater than in those of a more phlegmatic nature. 
Some women are almost prostrated with the pain of menstruation, 
while others hardly seem to mind it. The same may be said of the 
parturient state (Lazarus-Barlow, 5Y1, p. 478). 

Dilatation of the Pupil. — Dilatation of the pupil is produced 
by irritation of the sympathetic nervous system, particularly in 
the splanchnic area. This reaction can be made use of when 
estimating the tenderness of a part. Yet, in using it, one must 
not forget that pressure alone will produce dilatation of the 
pupil, especially when exerted on the abdomen, and that dilata- 
tion may also be produced by stroking or pinching the neck 
(Schmidt). Some idea of the dilatation due to pressure alone 
should be gained by stimulation of a non-painful part. Then, with 
this as a standard, an estimation of the dilatation due to pain can 
be made. This method is not available after the use of drugs, such 
as morphin, cocain, and belladonna, which have an action on the 

Amount of Morphin Necessary to Overcome Pain. — The 
amount of morphin necessary to ease pain is a good indication of 
its severity. Colic requires more morphin than many other vari- 
eties of pain. This is especially true of gall-duct or pancreatic 
duct colic, and renal colic is especially noted for its persistence and 

Appearance of Patient. — The appearance of the patient fre- 
quently is a reliable index of the variety and severity of his pain. 
As a rule, pain of great severity produces a cessation of muscular 
movement. To this there is one great exception, namely, the pain 
of colic. Here, whether the colic is of urinary, biliary or intesti- 



nal origin, the patient writhes, squirms and assumes all conceiv- 
able positions, at the same time crying out or moaning. These 
attacks come in paroxysms, a period of quiet following each 
attack. In colic, also, the patient presses with his hands, or with 
a bolster, upon the abdomen, and frequently lies with his limbs 
drawn up (see Figs, 87, 88). Here the tendency to exert pres- 
sure is seen in the characteristic way in which the hands are joined, 
the fingers being interlocked so that greater pressure may be ex- 

This picture is the exact opposite to that seen in peritonitis, 
where the patient is absolutely quiet, lying flat upon his back 



3 4 5 







-=«~*<PV-r-— ^ 





Fig. 37. — Hand Pressing on the Abdomen is Very Characteristic of 
Colic, i. e., of the Uterus or Intestine. 

1. Area of referred pain in phlebitis (femoral). Also area of distribution 
of ant. crural and area of pain reference in crural neural i^ia. 

2. Localized tenderness in phlebitis. 

3. Phlebitis (femoral vein). 
Hip joint disease. 
Psoas abscess (low). 

4. Ovary inflammation. ) 

Salpingitis. r It is more characteristic for patient in these con- 

5. Appendicitis. ) ditions to lie on back. 

with his limbs drawn up and hands frequently placed lightly 
upon his abdomen. He is very attentive, and is ever ready to 
ward off any touch or pressure with the other hand (see Fig. 86). 
To this posture the term ' 'abdominal protective position" has been 
given. Other characteristic postures are illustrated in Figs. 37, 
38. Headaches also give rise to characteristic postures, as may be 
seen in the Figs. 66, 67, 68. 



In pleurisy or intercostal neuralgia the patient assumes a rigid 
chest position, and, on close examination, it is noticed that the 
thoracic respiration is hindered. This is exactly opposite to what 
happens in abdominal inflammatory disease, in which the breath- 
ing is of the thoracic type, 
abdominal breathing hav- 
ing ceased entirely. 

When the patient moves 
with considerable pain and 
refuses to stand on a limb, 
and holds the joint in a 
flexed position, inflamma- 
tory disease of the joint 
should be suspected. The 
position assumed in dis- 
tention of the vesical blad- 
der is one in which the pa- 
tient inclines slightly for- 
ward, his back straight and 
rigid, pressing both hands, 
which are interlocked, 
over the lower segment of 
the abdomen.. Tumor or 
aneurysm is indicated as a 
rule by pressure over the 
diseased area. In men- 
ingitis the patient remains 
rigid because of the pain 
(Ryder, 35). 

The facial expression 
also is frequently a reliable index of the severity of pain. One 
expression which is indicative of the most severe pain is 
the so-called Hippocratic facies, in which the brow is con- 
tracted, the lips drawn back, the eyes fixed and the entire 
attention focused upon some intrinsic phenomenon. This is the 
characteristic facies of peritonitis, and when present is of serious 

Fig. 38. — Position Assumed in Uterine 
Colic, Intestinal Colic, and Dis- 
tended Urinary Bladder. 



import. In some patients, especially among those who have 
trained their features to express emotion, simulation is often prac- 
ticed ; jet, under close observation, one will notice, at times, some 

relaxation or change in ex- 
pression, especially when 
the patient thinks he is not 
being watched. 

Gestures indicative of 
pain are principally those 
in which the patient tries to 
ward off an imaginary or an 
actual injury. Motion as 
an indication of the severity 
of pain is of some value, 
but is chiefly of use in 
pointing to the structures 
which are involved. As a 
rule, all pains of moderate 
severity cause a loss of 
function of the part, and the 
patient usually lies quietly 
in bed, attentive but mo- 
tionless, except in cases of 
abdominal colic, in which 
each paroxysm is indicated 
by sudden and explosive 
movements. In children, 

Fig. 39. — Lacing Shoe Posture. 
In lumbago, spinal caries, hip joint dis- 
ease, sciatica, appendicitis and pelvic 
peritonitis, pain is experienced on the 
patient assuming this position. 

according to Eustace Smith, pain in the head is indicated by a con- 
traction of the brow; in the chest by a sharpness of the nostrils, 
and in the abdomen by a drawing in of the upper lip (Musser, 
p. 79). 

Patient's Description. — A patient's description of his suffer- 
ings is not of much practical assistance in deciding upon the 
severity of a pain. His descriptive ability, powers of imagination, 
and vocabulary cause it to vary greatly. One factor of im- 
portance is the persistence with which the attention of the patient 



is devoted to the pain, to the exclusion of other topics. Should 
he be consistent, and persist in his statements of its character and 
severity, and 'should his attention be not easily dra^\Ti away or 

Fig. 40. — Pain on Hyperextension 
OF THE Body. 

Hyperextension of the body produces 
pain in inflammation of the . ab- 
dominal viscera, adhesions, peri- 
tonitis, etc. 

occupied to the exclusion of the 
pain, it may be concluded that a 
pain of considerable intensity is 

Mechanical Factors.- — Pinching, 
chanical factors which are of slight 
gree of pain or tenderness. These 

Fig. 41. — Pain on Going Up- 

When, on going upstairs, pain is 
present in the right limb, it in- 
dicates appendiceal abscess or 
pelvic inflammation, and is 
due to the tension of the 
psoas muscle producing pres- 
sure or traction on the in- 
flamed area. The pain is 
greatest at the moment of 
raising the foot off the ground 

stroking, pressing are me- 
value in determining the de- 
are of little value because of 













the variations, both of pressure and of the resistance of the 
patient. The best mechanical aids are electricity, the von Frey 
hairs, algometers, and needles. 

In testing pain by means of electricity, two electrodes are 
used. They should be about the size of a knitting needle, and are 
placed from one to two cm. apart. In the following table, taken 
from Bernhardt, the figures showing the distances of the cylinders 
of the induction apparatus represent the minima of sensation, and 
the figures in parentheses represent the minima of pain in a 
healthy person: 

Tip of the tongue 17.5 

Palate 16.7 

Tip of the nose, eyelids, back of 

tongue, gums, lips 14 . 8 — 14 . 4 

Acromion, sternum, nape of neck. .13.7 — 13 
Back of the arm, buttocks, occiput, 

loin, neck, forearm, vertex, coccyx, 

thigh, back of the first phalanx, 

back of the foot 12.8—12 (12 — 9.2) 

Back of the second phalanx, back of 

the metacarpal bone, back of the 

hand, leg, distal phalanx, knee ... 11 . 7—11 .3 (10 . 2— 8 . 7) 
Palmar aspect of the head of the 

metacarpal bone, tip of the toe, 

palm of the hand, palmar aspect of 

second phalanx, hypothenar emi- 
nence, plantar aspect of the first 

metatarsal bone 10.9—10.2 (8 —4 ) 

These tables are of value in that they enable one to compare 
the relative sensibility of the different areas. Any decrease in 
the distance of the cylinders would indicate, of course, an increase 
in the sensitiveness of the part. 

Von Prey's hairs, also used in the estimation of sensibility, 
are hairs which have been so selected that they bend at different 


pressures. They are fastened to a small wooden rod at right 
angles. Previous to use, the weight necessary to cause them to 
bend is ascertained. 

In Head and Thompson's experiments, hairs sent by von 
Frey were used. IsTo. 8 would bend at 830 mgms. pressure; No. 
5 would bend at 360 mgms. pressure; 'No. 4 would bend at 230 
mgms. pressure; and No. 2 would bend at 100 mgms. pressure. 
In the intervals between use, they should be kept in a box, with 
the rods supported in such a manner that the hairs do not come 
in contact with anything (Head and Thompson, 206, p. 542). 

Algometers have been described by Head and others. A 
pointed instrument (as a needle) is made to press against the skin, 
and the amount of pressure is indicated by a scale which is 
attached to a resisting spring. This is the manner in which most 
of these instruments work. They are of considerable value, but 
are not yet in general use. 

I^eedles and pins are also employed in estimating sensibility, 
but their use involves several drawbacks. First, the pressure 
exerted by them is variable and cannot be controlled. Second, 
the sense of touch is apt to be confused with the feeling of pain. 
To avoid the latter, it is well to precede the pin with the tip of 
the finger, so that touch may be felt first, and later hyperalgesia, 
if the sensibility is increased. 

In making a thorough sensory examination according to Head's 
methods the following rules should be observed : Have the patient 
in an easy position and see that he is without physical discomfort, 
i.e., that the bladder and rectum are empty, and that he is neither 
hungry nor thirsty. The time of day best suited to the examina- 
tion is morning, when the patient has not entered upon the work 
and worry of the day. Weather conditions, also, are of some im- 
portance. A bright, sunshiny day will bring more uniform and 
reliable results than an examination upon a' dismal day. The 
surroundings must also be propitious. The room must be quiet, 
and no loud noises or talking should be permitted in the immediate 
vicinity. Above all, in testing the sensibility of a part, screen it 
from the observation of the patient. At the time of the examina- 


tion the external temperature should be warm, for anything which 
produces goose-flesh detracts from the value of the results. 

During an examination for sensibility both sides of the body 
should be compared. If a certain organ has been decided upon as 
the cause of the pain phenomenon it is necessary, in order to be 
sure that the decision is accurate, to reproduce the pain by trac- 
tion, pressure or manipulation of the organ. Should the proper 
organ be engaged, a reproduction of the pain will result. Unless 
this can be done, and in the absence of definite pathology, it is 
not wise to make too positive a diagnosis. On forming a conclu- 
sion, one should not forget that the ventral aspect is less sensitive 
than the lateral aspect, and the lateral aspect less sensitive than 
the dorsal aspect of the body. 

The sensations allied to pain having their basic principles in 
touch sensation are: (1) pleasant sensations; (2) agreeable sen- 
sations; (3) normal quiescent states ; (4) disagreeable sensations ; 
(5) pain sensations. At one end of the series we have pleasure, 
and at the other pain, while between the two we have all degrees 
of pleasant and unpleasant sensations. As the sensation becomes 
exaggerated at either end, we have a condition of unendurable- 
ness, for intense pleasure is just as unendurable as intense pain, 
and both manifest their intensity by promptly causing uncon- 
sciousness, from which the patient awakes, generally after the 
passing or subsidence of the causative sensation. Sometimes, fol- 
lowing unconsciousness from pain, the patient awakes, and, the 
pain being present, may become unconscious again. This pro- 
cedure may be repeated many times, until finally the pain-per- 
ceptive centers become fatigued or the pain disapj)ears. 


Associated with severe pain are certain symptoms which 
indicate to us the vast influence which a severe subjective con- 
scious irritation may produce upon the physical entity. With 
extremely severe pain there are often symptoms of collapse, such 
as cold sweats, weak pulse, and an anxious look. These are prac- 


tically the same phenomena as those which accompany any great 
emotion, such as fear, in which, owing to the induced fright, a 
vasomotor collapse takes place, the patient faints and is cold and 
clammy, with weak and very often rapid pulse. Happiness is 
also potent to cause somewhat the same condition, for we all know 
of the state of a man fainting from joy. In fact, in any great 
emotional exaltation a temporary loss of consciousness may occur, 
as in the sexual act, where in some cases the irritation to the 
glans or clitoris may produce such a succession of impulses that 
the receptive centers are overcome from the unaccustomed fre- 
quency and a temporary loss of consciousness results. The cause 
of this unconsciousness may be that the stimuli which are trans- 
mitted to the refraction center are referred to the periphery, and 
cause a vasomotor paresis which gives rise to lessened circulation 
in the brain. ^ As soon as unconsciousness occurs, the sensory per- 
ception is lost and the peripheral impulses to the vasomotors cease. 
The patient now regains consciousness, and is able again to per- 
ceive the exaggerated impulses (pain), whereupon he promptly 
relapses into unconsciousness. Thus an almost endless cycle is 
formed. The same phenomena occur in the case of extreme fear. 
Cases are quite common in which persons, who have become un- 
conscious at the sight of some grewsome object, are, on recovering, 
rendered unconscious a second time at the sight of the same 

It is amazing how miich one can suffer and still show no signs 
of it by physical deterioration. It is certain that every practi- 
tioner has seen sufferers from the most severe and constaiit neural- 
gias who are robust, and otherwise seem to be in perfect health. 

^According to Gowers ("Clinical Lectures," third series, r,. 7), sudden, 
intense pain, especially if felt in the abdomen or in the vicinity of the heart, 
may produce unconsciousness. The mechanism is supposed to Ve a direct action 
on the centers of the vagus, but syncope (unconsciousness) is only known to 
result if the pain is perceived. In man a cause of pain a lequate to produce 
syncope, while the patient is under the influence of an aneslhetic, has not been 
known. Hence, it seems doubtful whether the effect is due to a direct action 
on the vagal center. The facts suggest that it may be the r^isult of a profound 
influence on the sensory regions of the cortex, focused on the cardiac center in 
the medulla. 


After long periods the sufferer seems to acquire a tolerance for 
pain, so that he can, with a minimum of discomfort, withstand 
very severe attacks. On the other hand, all have seen cases in 
which the constant, steady and increasing pains of tubercular 
disease, trigeminal neuralgias, etc., have completely exhausted 
the patient, so that he has become thin, haggard, careworn and 
prematurely gray. In many cases worry and mental anxiety seem 
to have as much to do with the deterioration in physical charac- 
teristics of the patient as does the original pain. While the pain 
may not produce any apparent physical disturbance, the mental 
disturbances are manifold and remain more or less persistent even 
after the pain has entirely ceased. These mental changes are 
shown in irritability of temper, neurasthenia, etc. 

Respiratory System. — During severe pain the respiration, as 
a rule, is increased, and at the same time becomes very shallow. 
If the pain is due to inflammatory lesions in the abdomen, the 
breathing is of the costal type, while if it is due to disease of the 
thorax, the breathing is principally abdominal in character, and 
the chest is fixed as though it were in splints. These conditions 
exist even when the patient is unconscious, showing that they are 
reflex acts and not in any way the result of inhibitory voluntary 

Circulation. — An acute pain is almost always associated with 
an increase of the pulse rate, while a chronic pain is not so fre- 
quently associated with rapidity of the pulse. 

Loss of Equilibrium. — Pain may be so severe that a loss of 
equilibrium may result, as in the case reported by Erdman (Medi- 
cal Record, 1906, Vol. 69, p. 94), of a girl thirty-two years old, 
who, while at Mass, was taken with sudden, excruciating pain in 
the abdomen. Although she fell, she did not become unconscious. 
This loss of equilibrium may have been due to the fact that the 
stimulus produced by the pain was so great that it monopolized 
the entire sensorium, so that the equilibrizing perceptions from the 
sight, the aural, and the remaining peripheral senses were not 

Trophic Changes. — Certain disturbances in muscles, joints 


and bones may be associated with pain. These disturbances are 
either (1) functional or (2) metabolic. 

Both result in atrophy ; the first the so-called atrophy of dis- 
use, which results from inactivity caused by the pain, and the 
other an atrophy due to lack of metabolic interchange in the cells 
of the part. This metabolic disturbance may be in the nature 
of a lack of constructive power, or an increase of destructive 
change. In either case, the final result is a wasting and a diminu- 
tion in the power of the muscle. 

Preprotective Functions. — Associated with pain is what may 
be called the preprotective function, as exemplified in stom- 
ach disease, when the skin over the epigastrium, as well as the 
upper segment of the rectus abdominus, becomes somewhat tender. 
At the same time the rectus is in a state of partial contraction, and 
acts as a guardian, even before danger threatens. But as soon as 
pressure is exerted upon it the muscle hardens, and the pain, which 
may have been light before, now becomes acute. This illustrates 
how well designed is the protection of the viscera, for if the stom- 
ach itself were sensitive violence would reach and injure it before 
pain could be experienced ; but by the interposition of sensitive 
structures, which are coupled to a powerful muscular reflex exter- 
nal to the stomach, the diseased organ is effectually guarded 
against external violence. 

Elevation of Temperature. — There is no doubt that elevation 
of temperature is frequently produced by pain. There also is a 
close relationship between the conducting paths for pain and for 
those of the special senses, for hemianesthesia is sometimes ac- 
companied by impairment of the senses of smell, taste, and hear- 
ing, and amblyopia is sometimes associated with concentric con- 
traction of the visual field on the same side of the body. 


For a thorough and productive study of pain it is necessary 
that some reliable and simple means of recording pain phenomena 
should be found. This condition seemingly has been met by 



Harris (84), whose method is one of the best, and, at the same 
time, the simplest that has so far been devised. 

In his marking code, four primary characters are used: (1) 
a simple, unbroken line ; (2) a broken line, or dashes; (3) a dot; 
and (-i) a dot and dash. After the fourth markins; Arabic 











































I -!- 


y ■"■* 

• • • 
• 7 

• • 

• • 

• « 

• 7 • 

• • 
• • 

• • • 

• • 

• • 
• • • 

• • 
• . • 







Fig. 42. — Marking Code of Dr. Harris. 

numerals are used to indicate areas, centers, and radiations of 
pain, the numeral being placed at the point of the most intense 
pain and also on the line inclosing the pain area or indicating the 
pain radiation. Thus it may be seen that the primary characters 
can only be used in every fourth marking, but that the number 
of markings may be multiplied indefinitely. TigTire 43 illustrates 

'Tigure I, in Fig. 43, shows the first marking upon a patient, 
who we assume complained of a painful area, a center pain within 
the area, and a radiation of pain. It will be seen that the area of 
pain, its more painful center, and the radiation of pain from the 
area of pain are constructed from the first primary character. 

"Figure II, in Fig. 43, shows the second marking upon the 
patient who complained of a painful area with a more painful 
point within, which we designated as a center pain. The boun- 

( ^ 



^ — ^ ^-^^N 

' J 

^ rig. I 

• • 
fig. m 


^• — . — •—•— •— Fig. lY 

_ .- «? • ^ 

/ \ 

\ f 


/ F.^. Y 

9^ m a^. A>'-->^.. ^... •>w 

/• ^-^ 

re a 1 

-- - ' y^- - - ^ ~ '^ 


o ■w ^ 

-- —10. _ ^ 

\ y 

\ ^ yy Rg. X 
'o i. ^ 

— ^ ^ 
fig. IX 

Fig. 43. — Figures Showing the Application of the Marking Code of 

Dr. Harris. 

dary of the painful area is formed from the second primary char- 
acter, as is also its center of pain shown by the Greek cross. 

''Figure III, in Fig. 43, shows the third marking upon the 
patient who complained of simply a painful point. The four dots 


arranged in equi-latero-quadrangular formation show the manner 
of marking a j)ainfiil point or a center of pain from the third 
primary character. 

"Figure IV, in Fig. 43, shows the fourth marking upon the 
patient, illustrating a painful area and a center of pain. The 
markings are constructed by using the dot and dash, which consti- 
tute the fourth primary character. 

"Figure V, in Fig. 43, demonstrates a painful area and a 
center pain. 

"Figure VI, in Fig. 43, shows the sixth marking. The dashes 
are employed, as in the case of the second marking, but here the 
insertion of the Arabic numeral 6 indicates the number of the 

"In Figure VII, in Fig. 43, the Arabic numeral at the begin- 
ning of the dotted line shows the painful point, and the dotted 
line indicates the direction of radiation. 

^ "In Figure VIII, in Fig. 43, the boundary of the pain area is 
constructed from the fourth primary character, the insertion 
of the numeral 8 distinguishing it from the fourth marking. 
The location of the figure 8 at three different points indicates 
the location of the pain at three distinct points. 

"The Arabic numeral 9 in the ninth marking of the patient 
indicates a painful point, while the continuous arrowed line, con- 
structed from the first primary character, illustrates a radiation 
of pain from the marked painful point. 

"Figure X, in Fig. 43, shows a recurrence of pain in the 
same region as shown by the second marking of the patient. In 
this tenth marking of the patient the boundary of the area of 
pain is constructed from the second primary character. The 
number 10 in the outer boundary line of the area distinguishes 
this boundary line from the boundary line of the second marking, 
which occurred in the same region having a longer and narrower 
area. The number 10 in this tenth marking shows the location 
of the center of pain, and distinguishes it from the center of 
pain indicated by the Greek cross of the second marking of this 


A permanent record may be made on the patient's chart by 
transferring the outlines on the patient's body to a stamped figure, 
being careful that the relative positions of the outlines correspond 
both with the bony landmarks on the figure and on the patient's 



The nervous system, since it is the carrier of impulses from 
one portion of the body to another, and since its organization is 
much more delicate than that of any other structure of the body, 
suffers from disturbances, which, when affecting the sensory ele- 
ments, are, as a rule, announced by pain. For systematic consid- 
eration the following divisions may be made: (1) nerve terminals; 
(2) nerves or nerve trunks; (3) nerve plexuses; (4) nerve roots; 
(5) cord lesions; and (6) pontine, mid-brain and cortical 



Affections of the nerve receptors are due, as a rule, either to 
inflammation, to toxemia, or to pressure. These have been con- 
sidered in part in the section on parenchymatous pain (q. v.). 

Affections of the nerves or nerve trunks are due, as a rule, to 
the following causes: (a) congestion; (b) inflammation; (c) in- 
jury (traumatism, pressure) ; and (d) toxemia. The milder 
grades may, for purposes of convenience, be termed neuralgias ; - 
the more severe affections, neuritis. 

The distinctions between neuralgia and neuritis are quantita- 
tive rather than qualitative. It is largely a matter of degree. A 
severe neuralgia may be termed a neuritis ; a mild neuritis a neu- 
ralgia. We cannot, therefore, insist upon a separation of the two 
conditions. One finds one or all of the causes operative in pro- 
ducing either a neuralgia or a neuritis and the resulting lesion de- 


pends largely upon the severity of the action of the exciting factor. 
Thus exposure to cold may set wp a neuralgia in the facial from 
involvement of its sensory roots (the geniculate ganglion), or it 
may cause a true neuritis, involving the motor components, as v^ell. 
Similarly an inflammatory reaction in a mixed nerve may cause 
only slight pain, the sensory components being involved but 
slightly, or it v^ill bring about both sensory and motor disturbances 
with distinct neuritis symptoms; slight traumata, as well as tox- 
emias, cause quite similar pictures. 

Certain meningeal diseases of the cord, as well as ganglion 
affections, give rise to exquisite neuralgic symptoms without any 
of the usual motor complexities of a neuritis. 

We shall here discuss the so-called neuralgia, although it 
should be remembered by the reader that one is continually stray- 
ing into the field of neuritis. 

Anstie, in his classical work on "l^euralgia and the Diseases 
Which Kesemble It" (1871), gave one of the first English presen- 
tations of the general subject. Bernhardt, in E'othnagel's large 
system, has given the most extensive of recent discussions of the 
whole subject. However, he was incorrect in regarding neuralgia 
as a separate entity. It should not be so regarded, with the pos- 
sible exception of a few conditions, for instance, those which 
cause such a change in the conducting apparatus that a light 
stimulus is interpreted as painful, or pain is produced without 
any apparent stimulus. Such a condition may follow slight chill- 
ing of the surface, or the lodgment in the nerve or its sheath of 
toxic substances, either heterotoxic (phosphorus or mercury), or 
autoxic, the result of deranged metabolism. Such a condition is 
present in influenza, and also in old age, when, because of im- 
paired circulation, the tissues are not properly nourished. To 
these pains the term neuralgia may be applied. As early as 1873,^ 
Loomis also applied the term to conditions in which there is a 
disturbance of nutrition. Neuralgia seems to be without recog- 
nizable pathology ; at least, no uniformity exists as to the kind of 
pathology which is present. By some it is thought to be a form of 

1 Loomis, Med. Eecord, N. Y., 1873, p. 473. 


neuritis (neuritis of the nervi nervorum, Thompson, 352), but it 
differs considerably from neuritis in its pain phenomena. 

Etiology. — By many authors neuralgia is the name given to 
a nerve-pain which is produced by any of the following causes : 

Exciting Causes. — Intraneural, in which the exciting cause 
is found in the nerve fiber or its central origin. This cause may, 
in many cases, be the presence of toxic materials producing irri- 
tation and pain somewhat akin to the action of rheumatic poisons 
in rheumatic myalgia, in which the poisons act upon the terminal 
filaments of the sensory nerves distributed tO' the muscles. Under 
this heading we would include all those pains of infectious origin 
which do not result definitely from an inflammatory change in 
the nerves, such as occur in acute infectious diseases (influenza, 
tonsillitis, common colds), malaria, gout, nephritis, anemia 
(chlorosis), diabetes, syphilis, typhoid fever, small pox, constipa- 
tion, and gonorrhea. Many consider copper, lead, arsenic, alco- 
hol, nicotin, and mercury causes of neuralgia; others class them 
rather as irritant poisons with the production of neuritis. Other 
causes are molecular changes in the nerve itself, the character of 
which we do not know, although many regard them as a mild de- 
gree of inflammation. Also included under the heading of mole- 
cular disturbance pain are pain caused by exposure to cold (we 
are all aware of the headache produced by going against the wind 
on a cold day) and post-hoc-neuralgia, a term given to those con- 
ditions in which, following the removal of the cause of the neu- 
ralgia, there is a persistence of the pain, due, perhaps, to continued 
molecular change in the nerve substance or ganglion, which time 
alone can, but does not always remove. As an instance of this 
may be mentioned the pain persisting after removal of gall stones, 
after the removal of carious teeth, and after cure of a gastric ulcer. 
Sometimes these are called "habit pains" (q.v.). 

Extraneural, under which we would include pressure by new 
growths, tumors, or bony processes, by foreign bodies, soft tissues, 
glands, bone (especially when the nerves pass through bony fora- 
men), cicatrices, misplaced viscera, hernia, aneurysms, enlarged 
uterus, etc., upon the nerve. 


Traumatism, such as injury of the nerve by a blow, by forcible 
contact with a foreign body, by the pinching of a nerve between 
two bones, as pinching of the intercostal nerves between two adja- 
cent ribs. Fractures by pressure from fragments, or from the 
callus, cause nerve pain. Dislocation of a bone may also cause 

Infection has been mentioned as one of the causes, and perhaps 
it is the chief one. Cases of epidemic intercostal and of supra- 
orbital neuralgia have been described, as well as the neuralgia 
associated with typhoid fever and rheumatism. It is reasonable 
to suppose that the infective germs can lodge and grow in nerves 
as well as in blood and interstitial tissues, for it has been defi- 
nitely proven by many observers that typhoid fever germs are, 
in the later stages of the disease, freely circulating in the blood. 
Pneumococci, streptococci, and various other germs have also been 
isolated in pure culture from the blood ; and these wandering 
hither and thither in the tissues locate themselves where there is 
the least resistance, be this in bone, tendon, nerve, or muscle. 
Should the nerve be the habitat, a mild neuritis is produced 
and this causes pain. 

Peedisposing factors leading to the production of neuralgia 
are inherited predisposition, the use of alcohol, tobacco and 
drugs, neurasthenia, and excessive sexual indulgence. Age seems 
also to act as a predisposing factor, those of advanced age being 
more susceptible than those who are younger. The other so-called 
pains are classified under referred, projected, sympathetic pain, 
et cetera, under which they will be described (q. v.). 

Symptoms. — In the case of pain occupying any restricted 
area it is well to make an examination for local inflammatory 
changes in the skin and subjacent tissues. Should they be absent, 
with the skin very sensitive to light pressure and the deeper tissues 
not so sensitive, we may conclude that the cause of the pain is 
either a neuralgia or a neuritis. 

If neuralgia is present there are points of hyperesthesia and 
the course of the nerve is not painful to pressure, while in neuritis 
the course of the nerve is tender to pressure, and there are no 


painful points. Should neuralgia be suspected, we must seek 
the cause, and consider acute infections, reflex irritations, as the 
cephalgias due to visceral disorders ; referred pain, as earache due 
to decayed teeth ; projected pain, as in the head after Gasserian 
'^'anglion resection, and sympathetic pain, "when one sensory center 
is affected by changes in another center, and pain is felt as coming 
'^rom the area of distribution of nerves arising in this center. 

The pain of neuralgia may be constant and dull, or there may 
be periods of freedom from pain and then times of sudden and 
severe pain. These paroxysms of pain occur at intervals varying 
from a few seconds to as many weeks. The duration of an indi- 
vidual paroxysm varies from a few seconds to as many minutes. 
Sometimes, after the pain reaches its acme it becomes almost con- 
tinuous and may last for weeks. The onset in many cases seems 
to be without any causal condition, and may be sudden or gTad- 
ual. Abortive attacks may come quickly and quickly disappear. 
Sensations of cold, itching, and numbness in the areas of the skin, 
which subsequently are affected by the neuralgia, are premoni- 
tory signs of an attack. The pains are of a burning, darting, bor- 
ing, cutting, piercing, biting, or pulling character. In some cases 
there is an intermittency in the paroxj^sms, which may come every 
day or every second or third day. When this occurs examine for 
malaria. The pain generally follows the course of a peripheral 
nerve. It may remain confined to one nerve area throughout its 
course, or it may suddenly shift from one area to another. At 
times it is confined to a small area, but most often it radiates 
through large areas and may run toward the periphery (neural- 
gia descendens), or from the periphery inward toward the cen- 
ters (neuralgia ascendens). 

AnestJiesia dolorosa (q. v.) sometimes is present in these con- 
ditions, especially when the nerve trunk is subject to pressure due 
to an irritative lesion. In neuralgia tactile sensation also is some- 
times lost. 

Local PoiJits. — Pressure points, first described in 18-41 by 
Valleix, are called Valleix's points. Light pressure on these points 
sometimes aggravates the pain, while heavy pressure relieves it. 


In other cases the reverse is noticed. Pain may he elicited by pres- 
sure with a single finger-tip; 

The galvanic current sometimes produces pain when finger 
pressure fails to produce it. (Technique: Place the positive pole 
on any part of the body, preferably over some part of a nerve; 
hold it stationary, and run the negative pole along the course 
of the nerve.) In neuralgia Yalleix's points are found at the 
point of emergence of the nerve trunks, at sections where a nerve 
trunk traverses a muscle to reach the skin, at the point where 
a nerve fiber breaks up into branches, and at points where the 
nerve becomes very superficial. The painful points along the 
course of nerves in neuralgic affections may be due to irritation 
of fine terminal-sensory filaments, which are distributed to the 
sheath of the nerves (Jelliffe). 

Distant Points. — "Points douloureux apophysaires" of Trous- 
seau, or distant painful points, are also found in neuralgia. 
These are located in the spinous processes of the vertebra, be- 
tween which the roots of the affected nerves leave the verte- 
bral canal. The spinous processes in the region of the middle 
cervical vertebra are very sensitive in neuralgia of the trigeminal 

While painful points vary greatly and sometimes are recog- 
nized only at the time of the paroxysm, they may exist all the 
time and become more painful only at the time of the paroxysm. 
Pressure on the painful points may in one case produce an attack, 
while in another case, it may abort the attack. The effect is some- 
times lessened, sometimes intensified, depending upon whether the 
pressure is light or heavy. Light pressure sometimes produces a 
paroxysm, while heavy pressure sometimes causes its disappear- 
ance. After the neuralgia has existed a certain length of time, 
atrophy of the nerve may occur and the pain may subside, espe- 
cially when it is due to pressure along the course of the nerve. 

Vasomotor Changes. — In acute and recent attacks, because of 
the contraction of the vessels and stimulation of the vasomotor, 
there may be at first pallor of the affected area, followed by flush- 
ing. In chronic neuralgia there is chronic flushing, due to vaso- 


motor paresis. In later attacks there is generally flushing of the 
skin on the affected area. In trigeminal neuralgia there may be a 
pulsation of the temporal artery on the affected side. In some 
cases a swelling of the affected side occurs, and this in time leads 
to chronic thickening. 

Trophic Changes. — The skin is sometimes thicker than nor- 
mal ; or, as a rarer condition, it may be thinner, due to cutaneous 
atrophy. The hair on the affected side of head in trigeminal neu- 
ralgia sometimes becomes coarse or rough, and falls out, or it may 
become gray. Areas of gray hair may alternate with the natural- 
colored hair. In some cases the hair grows profusely. Other 
changes, as herpes, desquamation, eczema, and pemphigus, are 
fairly common. The secretory and excretory apparatus are also 
affected. Saliva and tears are often increased on the affected side 
in trigeminal neuralgia. Sweating is common over the affected 
part, and urine is often excreted in abnormal amounts. The nasal 
secretion in a trifacial neuralgia is at times tinged with blood. 

Muscular Changes. — ^Atrophy of the muscles on the affected 
side is common. It is due to lack of motion, because of pain. 
This is very slow of onset, and after a certain time remains sta- 
tionary. Trophic muscular changes generally indicate a more 
extensive involvement (protopathic system). 

Muscular contractions occur ; at times they are clonic, at other 
times tonic. Slowing of the heart's action has been observed dur- 
ing a neuralgic attack. Movement is often impossible, because of 
the irritation produced in the sensory nerves. Walking and flex- 
ing of the thigh will often produce pain in cases of sciatica. Eat- 
ing will frequently produce pain in cases of trigeminal neuralgia. 
Pupils are often dilated, the dilatation being unequal. Associated 
neuralgia may be present in some cases. Here the pain gradually 
appears on the opposite side of the face, and may then entirely 
disappear in the region where it commenced. 

Duration of Neuralgia. — Sometimes the disease ends after 
one or two attacks, or it may persist for long years, even for an 
entire lifetime. 

Diagnosis of Neuralgia. — ]Sreuralgia can only be diagnosed 


by exclusion, and is only justifiable when all otlier causes having 
an anatomical basis for the pain production have been excluded, 
such as pressure from growths, inflammatory exudates, misplaced 
fragments of bone, etc. The term neuralgia is often only a cloak 
for ignorance. It indicates that the diagnostician has not been 
able to localize the cause of the painful condition. It is the same 
as calling .a pain in the head headache, or a lesion of the heart 
heart disease. 

DiFFEKENTiAL DIAGNOSIS of neuralgia should be made from 
painful muscular lesions. Here the muscle is tender to pressure, 
and there are swelling and thickening. Pain never extends be- 
yond the region of the muscle. Inflammation of the bones or 
periosteum is also to be distinguished. In these there are swell- 
ing and tenderness in the bones affected. Inflammation of the 
joints sometimes is mistaken for neuralgia; it is differentiated 
by the swelling and tenderness of the joints and the pain on mov- 
ing them. I^euritis from a differential diagnostic standpoint 
offers the greatest difficulties. It is different from neuralgia, in 
that neuralgia is but the name of the sensory condition, while 
neuritis is the name of the pathological entity which is present. 

Syphilitic Neuralgia. — This form of neuralgia, because of the 
frequency with which it is entirely overlooked, merits separate 
consideration. ]N^euralgia may occur during any of the three 
stages of syphilis. During the first stage it is manifested princi- 
pally by fugitive transitory pain over the entire body. It is 
rather an aching than a well-defined pain. In the second stage, 
the pain also is fugitive, is worse at night, and shows remarkable 
improvement under syphilitic treatment; while in the third stage 
the pains are more fixed and are due to pressure from syphilitic 
changes in the surrounding tissues (gumma, exostosis), or they are 
produced by changes in the nerve itself, due to syphilitic processes 
such as are found in locomotor ataxia. 

Types of Neuralgia According to Localization. — The principal 
types of neuralgia, according to localization, are: (1) trigeminal; 
(2) brachial; (3) intercostal; (4) circumflex; (5) sciatic; (6) 
peroneal; and (Y) visceral. 


Trigeminal I^eukalgia (Tic Douloureux). — ISTeuralgia may 
occur in any of tlie branches of the iSfth nerve. In some cases 
lesions have not been demonstrable, but in the majority of in- 
stances some disease of the Gasserian ganglion has been found in 
intractable cases of tic douloureux. 

1st Br. 5th nerve. 
3rd Br. 5tti nerve. 

2nd Br. 5th nerve. 

Points of tenderness 
in involvement of 
3rd division of 5th 
-—- — Points of tenderness 
in Involvement of 
the upper cervical 

Fig. 44. — Areas of Neuralgic Pain. 
The first branch involvement is seen most often by physicians; the second 
and third division involvement are seen most frequently by dentists. 
The dots indicate VaUeix's points of tenderness in neuralgia of the 
fifth nerve. The crosses indicate the points of tenderness in cervico- 
occipital neuralgia. 

The most important of the peripheral trigeminal pains due to 
lesions of the nerve are in the teeth. In some cases the pain is 
referred to areas supplied by a different branch of the nerve than 
that which supplies the particular tooth. The reasons for this are 
not knoM^n exactly. In other cases a central pain is referred to 
the teeth. One of the most frequent mistakes of dentists is to 
consider a tic douloureux as being due to teeth disorders. The 
result is the extraction of all the teeth for a lesion which really 
is in the Gasserian ganglion. 


The nose in many cases acts as a primary cause for neuralgia 
(referred pain) of the upper branch. Thompson mentions a case 
of trigeminal neuralgia which was caused bj a piece of necrosed 
bone in the nose. 

Lange calls attention to neuralgia being mistaken for incipient 
tabes. Diagnostic differentiation in tabes is the lack of sensitive- 
ness of the nerve trunks, and generally the simultaneous affection 
of the trigeminal and occipital nerves. On the other hand, a tabes 
may have its initial symptom in a trigeminal neuralgia. 

Blair gives the following as characteristics of trigeminal neu- 
ralgia: (a) The pain is generally sudden in one branch of the 
fifth nerve; (b) it is paroxysmal and always returns in the same 
spot ; (c) it is spontaneous, or is 23roduced by certain definite stim- 
uli peculiar to the individual; (d) no primary anesthesia is pres- 
ent over the involved nerve; (e) there is no tenderness of the 
trunks of the involved nerve. 

When trigeminal neuralgia is present in any or all branches 
of the fifth nerve, examine the branch involved from its area of 
distribution to its point of emergence on the face. True trigemi- 
nal neuralgia is due to a lesion of the Gasserian ganglion, and 
should not be confused with the nerve pain arising from inflam- 
mation of the nerves, tumors of the nerves, injury of the nerves, 
pressure upon the nerves from new growths (as aneurysm of the 
carotid artery), tuberculosis of the bony foramen through which 
the different branches pass, gummata, and malignant growths. In 
infectious diseases, as influenza, malaria, and typhoid fever^ 
the severest pain is felt at the supraorbital foramen (Schmidt). 

The pain of trigeminal neuralgia is probably the most severe 
of any to which man is heir. As a rule it is unilateral. When 
at its worst the sufferer may cry out, roll, and toss in his agony. 
With a constant, steady pain, there occur paroxysms of greater 
severity, which are so intense that the patient would welcome any 
event, even death itself, if it would relieve him. If the inferior 
or middle branches are involved, eating becomes an utter impossi- 
bility, and drinking is only accomplished with great distress. The 
patient is in constant dread, for when the pain is somewhat les- 


sened the slightest touch, even the vibration from a slammed door, 
will again cause a paroxysm. These attacks last from a few 
minutes or hours to several days. 

Valleix's points, which are present, are described by Jelliife: 
(a) for the first division of the fifth nerve, as being located at 
the supraorbital notch, the external angle of the upper lid, the 
upper, outer aspect of the nose, and the globe of the eye ; and (b) 
for the second division at the infraorbital notch, the molar bone, 
opposite the upper last molar, at the outer angle of the mouth, 
and on the roof of the mouth. The points of tenderness (c) in the' 
inferior maxillary involvement are just in front of the auditory 
canal, the side of the tongue, the border of the chin, and Troils- 
seau's points over the first and second cervical vert-ebral spines. 

Brachial JSTeukalgia. — Brachial neuralgia, or neuritis, is 
due to a lesion of the brachial plexus. The brachial plexus arises 
from the anterior roots of the lower four cervical nerves and the 
upper half of the first dorsal nerve. These then unite into trunks, 
the fifth and sixth uniting to form th» upper trunk, the seventh 
nerve forming the middle trunk, and the eighth cervical and one- 
half of first dorsal nerves uniting to form the lower trunk (Fig. 
45). These trunks then divide into an anterior and a posterior 
part, the anterior portion of the upper two trunks again uniting to 
form the upper cord, and the posterior divisions of the upper and 
middle trunk uniting to form the middle or posterior cord. The 
inferior trunk continues as the inferior or lower cord. Each of 
these cords is made up of both motor and sensory nerves. 

The sensory cutaneous nerves arising from the upper cord of 
the plexus are the musculocutaneous, from the fifth, sixth and 
seventh cervical roots. Those arising from the lower or inner 
cord are the lesser internal cutaneous, which arises from the first 
dorsal; the internal cutaneous, arising from the eighth cervical 
and the first dorsal ; the ulnar, receiving its fibers from the eighth 
cervical and first dorsal roots; and the meridian (inner head), 
arising from the sixth, seventh, and eighth cervical and the first 
dorsal nerves. From the middle cord arises the circumflex, re- 
ceiving fibers from the seventh and eighth cervical; and the mus- 



culospiral, radial branches receiving fibers from the seventh, eighth 
cervical and first dorsal roots. A lesion in any one of the cords 
of the brachial plexus may produce pain in the area of distribution 


^ 5H00LD£ft JOiNT 

^ ' ■ '^'^ -DELTOID 

,6K1N OVER lOWER '/i 





Fig. 45. — Brachial Plexus. 
of any of the nerves arising from it. A lesion on any of the 
nerves derived from the brachial plexus will cause pain in the 
area of distribution of the nerves involved. The areas of distribu- 


Radial. Musculocutaneous. Supraclavicular. 

Palmar Palmar 
cutaneous branch 
branch of 
of ulnar, ulnar. 

Fig. 46. — ^Areas op Distribution of Nerves Derived from the Brachiai, 


tion are shown in the accompanying figures (Figs. 46, 47), 
Should the lesion occur above the cords, and be in one of the trunks, 
it is very easy to define it by referring to the figures showing the 

Musculospiral. Radial. 

Circumflex. Internal cutaneous. Ulnar. 

Fig. 47. — Areas of Distribution of Nerves Derived from the Brachial 




distribution areas of the nerves forming the brachial plexus. It 
is only necessary to remember that the upper trunk is formed by 
the fifth and sixth cervical, the middle trunk by the seventh cer- 
vical, and the lov^er trunk by the eighth cervical and the first dor- 
sal nerves. These figures (Figs, 46, 47) clearly show the areas 
of pain in lesions of the different cervical nerves. The accompany- 
ing outlines (compiled from Piersol and Gray) show the nerve 

Posterior thoracic 


External anterior tho- 

5 cervical 
5 cervical 

5 cervical 

6 cervical 
6 cervical 

6 cervical 

7 cervical 

8 cervical 

7 cervical 

Internal anterior tho- 

8 cervical 
8 cervical 
8 cervical 
8 cervical 
8 cervical 

1st D. 


5 cervical 
5 cervical 
5 cervical 

6 cervical 
6 cervical 
6 cervical 
6 cervical 

7 cervical 
7 cervical 
7 cervical 
7 cervical 


Musculocutaneous .... 

1st D. 
1st D. 

Lesser internal cuta- 

1st D. 

Internal cutaneous. . . . 

8 cervical 
8 cervical 
8 cervical 
8 cervical 

1st D. 


1st D. 



5 cervical 

6 cervical 
6 cervical 

7 cervical 

1st D. 
1st D. 

roots from which the divisions of the brachial plexus are derived, 
and are very useful in localizing neuritis, which affects both the 
motor and the sensory fibers of the nerves involved.^ 

These primary distribution areas are represented in the out- 
lines in such a manner that they clearly define the area of distri- 
bution of the different nerves forming the brachial plexus. Dia- 

1 The table may be used to define the cervical nerve, root or cord zone in- 
volved; for instance, suppose pain was felt on the ulnar side of the arm and 
over the shoulder, on referring to the figure one sees that the pain is in the 
area of distribution of the ulnar and circumflex nerves, and on referring to 
the table one sees that while the circumflex arises from the seventh and eighth 
cervical and the first dorsal, "the ulnar arises only from the eighth cervical and 
first dorsal. The lesion may involve the seventlr and eighth cervical, and the 
first dorsal, but if it involves the first dorsal, the lesser internal cutaneous wouki 
also be involved. Since it is not, the first dorsal must be excluded. Examina- 
tion of the internal anterior 'thoracic will show whether the eighth cervical or 
the seventh cervical are the ones affected. If it is involved in the pain phe- 
nomena also the eighth cervical is the nerve affected. 


































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C » 

m S 


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o a 






grammatic outlines of the distribution area of the cords compos- 
ing the brachial plexus are shown in Figures 48-53. A lesion on 
one of these nerves would produce a disturbance in the entire 
distribution area of the nerve below the point involved. 

Fig. 49. — ^Areas of Distribution of the Different Cords of the 
Brachial Plexus. 
The areas marked U are supphed by the upper cord. Those marked M by 
the middle or posterior cord, while those marked L derive their supply 
from the lower or inner cord. The area containing crossed hnes and 
marked U M is supphed by both the upper and lower cords. 

When the pain is bilateral, and affects the areas of one or 
more segments (see figure showing cord zone distributed) of the 
cord, disease of the vertebra or tuberculosis should be looked for ; 
or, if it affects the cord itself, tabes should be sought. The asso- 
ciation of herpes indicates involvement of the posterior ganglia. 

Unilateral pain occurring (a) within the boundaries of a par- 
ticular cord-distribution area, (b) within the distribution area of 
d cord trunk, or (c) of one of the cervical nerves, or (d) even of 
the nerves given off from the brachial plexus, should always 

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cause a search to be made for the lesion in the special nerve seg- 
ment in which it has been localized. Lesions causing such a condi- 
tion are those producing pressure, as axillary tumors, sarcoma, 
aneurysm oJ the subclavian or axillary artery, abscess, and en- 
largement of the cervical and axillary lymph glands. Owing to 
the close relationship of the trunks and cords forming the brachial 

plexus, it is very 
unusual for one to 
be affected to the 
exclusion of the 

A method of 
making pressure 
on the brachial 
plexus and so 
causing pain to ap- 
pear in the distri- 
bution areas in- 
volved is shown in 
the figure. 

All of the in- 
stances given here 
are not, in the 
strict sense of the 
word, true cases of 
neuralgia. The 
term neuralgia should be used only to define those lesions of the 
nerves giving rise to pain and in which there is no apparent pathol- 
ogy. Such a condition is found in anemia and toxemia. In other- 
cases pain produced by pressure is referred to the area of distribu- 
tion of the nerve, and is a referred pain, while pain resulting from 
an adjacent inflammation is due to a neuritis or to pressure from 
the inflammatory exudate. Both cases resemble referred pain ; but 
since it is common to consider these pains under neuralgia, and 
neuralgia itself means pain, they have been placed under this 
heading. In cases in which inflammation is the cause of the 

Fig. 54. 

-Method of Eliciting Pain in Brach- 
ial Neuralgia. 


neuralgia a considerable part of the local pain is as much the 
result of the inflammatory invasion of the connective and muscu- 
lar tissues of the aifected part as it is of nerve involvement ; 
indeed, it is probable that every one of the above so-called neu- 
ralgias will be found to be a neuritis. 

The pain in brachialgia is similar to all other neuralgic affec- 
tions. It generally occurs in sharp paroxysms, in the intervals 
between which there is no pain ; yet, in some cases, the pain may 
be constant, and of a dull, aching type. In all cases sharp 
paroxysms of greater severity occur at regular intervals. In the 
early stages of the disorder, the pain is a dull, generalized ach- 
ing, and involves the entire arm ; then, as the attack persists, it be- 
comes localized to the distribution area of one or more of the 
cords of the brachial plexus (page 155). The pain may be so 
severe that the jDatient cannot sleep, and even though he should 
momentarily doze he is awakened by sharp paroxysms of pain. 
All sudden and forcible motions make the pain worse, but 
gentle manipulation is painless. In brachial neuralgia, stretch- 
ing of the arm causes pain in the region over the posterior 
margin of the scapula. The paroxysms frequently come on 
at night and it is nothing unusual for the patient to awake 
in the morning suffering from arm pains of the greatest 

The attacks may last for a short time, a few minutes, or a 
few hours ; then again, they may be present for weeks or months, 
during which time the ]3ain may be interrupted by periods of rest 
or aggravated by paroxysms of great severity. An individual 
attack lasts, on an average, almost two or three weeks. The pa- 
tient seeks rest, and it is common to find him sitting in an arm- 
chair, nursing the diseased arm with the sound one. In some 
cases the patient lies down and places the arm across his chest 
or abdomen. 

Location of the Pain. — In brachial neuralgia the pain may in- 
volve the entire arm, but generally only the upper part of the 
arm and the shoulder are most severely affected. The reason for 
this is that the circumfl.ex and the internal cutaneaus nerves sup- 


plj the shoulders and the upper part of the arm, and are the most 
subject to injury. 

Should the pain be entirely above the shoulder, it is due to 
involvement of the acromial and clavicular branches of the fourth 
cervical. If the pain is over the shoulder, or is at its anterior and 
outer aspect, it indicates involvement of the circumflex (Figure on 
page 154). Since the shoulder joint is also supplied by the cir- 
cumflex nerve, movement of the joint may cause pain in the dis- 
tribution area of this nerve. If the circumflex is involved the pain 
is confined to the cutaneous area of the distribution of this nerve ; 
but should the pain be the result of a lesion of that part of the 
cord from which the circumflex arises, the pain is felt also down 
the arm in the area of distribution of the musculospiral nerve 
which arises from the posterior cord in common with the circum- 
flex. Should the pain in the area of distribution of the circum- 
flex be associated with pain over the scapula, under the clavicle or 
in the neck, it indicates that it is the fifth root which is involved. 
In disease of this root pain may also extend down the arm in the 
distribution of the musculocutaneous nerve. 

Pain on the ulnar side of the arm, extending almost half-way 
around and involving the hands and fingers, except the dorsal 
and external surface of the thumb, the index finger, and the adja- 
cent surfaces of the index and the ring fingers, indicates involve- 
ment of the middle cord of the brachial plexus. Pain in the radial 
side of the forearm generally indicates involvement of the upper 
cord of the brachial plexus. Depending on the location of the 
lesion, the muscles may or may not be involved. A square block 
has been placed on the upper trunk of the brachial plexus, just 
before it divides into the musculocutaneous, and the branch help- 
ing to form the median. A lesion at this point would not disturb 
the muscular and cutaneous supply of the nerves given off above 
this level, while the supply given below this portion would be 
disturbed in the manner described above. By placing a block 
on any part of the nerve, the resulting disturbance can easily be 

In the early stages of brachialgia the pain is diffused over 


the entire arm, forearm and hand, and runs down into the fingers, 
though it usually involves only the first, second and third fingers 
(Dana). According to Dana, neuralgic pain in the forearm is 
very rare. 

Tenderness. — I^euralgia, in the absence of neuritis, causes 
little or no tenderness along the course of the nerves, nor over the 
site of the brachial plexus, though there are well-defined tender 
areas in which points of maximal tenderness are located. Accord- 
ing to Dana, these areas of maximal tenderness do not always 
correspond with the tender points of Valleix. It is common for 
patients to rub those tender areas with some form of liniment in 
the endeavor to ease the pain. It is needless to say that this pro- 
cedure is productive only of irritation and inflammation at the 
site of the rubbing, without any alleviation of the pain. Others 
engage masseurs, who put the patient through a course of treat- 
ment, generally with a negative result, though in some cases they 
irritate the nerves, and increase, instead of decrease, the pain. 

The tender areas are located on the anterior and posterior 
surface of the arm and shoulder. Those on the anterior surface 
are found over the outer third of the clavicle and infraclavicular 
fossa, over the deltoid, at the outer surface of the arm, over the 
inner surface of the arm just above the elbow, over the middle of 
the forearm, and (one) over the Avrist (Gowers). On the pos- 
terior surface the areas are found over the scapula in the supra- 
spinatous fossa, over the posterior margin of the scapula, over the 
upper surface of the arm where the arm and the shoulder join, 
over the middle of the arm, and over, the middle part of the fore- 
arm. The areas along the posterior margin of the scapula are in 
close relation with the points of tenderness of occipital neuralgia. 
They lie over the second and third cervical spines. They are also 
closely related to the points of tenderness of cervicobrachial neu- 
ralgia, which lie over the first or second dorsal spines (Trousseau), 
and of brachial neuralgia, whose points of tenderness lie over 
the third and fourth dorsal spines. 

Associated symptoms may be present, but they are not com- 
mon unless a neuritis is present. When that is present there are 


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generally some muscular paralysis and atrophy. At first the elbow 
jerk is a little exaggerated, and then becomes decreased, and anes- 
thesia is absent. In brachialgia these changes, if present at all, 
are a later development. In the early stage no physical change 
can be noticed in the arm except a slight swelling and some flabbi- 
ness of the tissues. 

Circumflex Neuralgia. — Circumflex neuralgia is more com- 
mon than one would naturally suppose, and of all neuralgias it is 
probably the most frequently wrongly diagnosed, and often mis- 
taken for rheuma- 
tism of the shoul- 
der joint. From 
this it is to be dis- 
tinguished by the 
absence of swell- 
ing in the joint, 
the more or less 
intermittent pain, 
presence of exacer- 
bations, etc. Per- 
verted sensations 
are also present, 
as tingling, burn- 
ing, and numb- 
ness. Tenderness 
over the deltoid 
and teres muscles 
is present, and is 
very severe over 
the line of the nerve. The causes of circumflex neuralgia, accord- 
ing to Disna (598), are toxic materials (as arsenic), infections 
(as tuberculosis), diabetes, rheumatism, gout, draughts, injury 
to the shoulder, blows across the deltoid muscle, fracture of the 
surgical neck of the humerus, and dislocation of the shoulder 

Intercostal Keuralgia. — Intercostal neuralgia occurs, as a 

Fig. 55. — Method op Eliciting the Points of 
Tenderness in Intercostal Neuralgia. 



rule, rather suddenly, and comes on after exposure to cold, etc. 
It appears in paroxysms, which are very severe v^hile they last, 
the pain seeming to extend around the chest. Any exposure to 
cold excites a paroxysm. Pressure pain over the nerve is present, 
and it is specially marked (a) near the spinous i)rocess of the 
vertebra; (b) near the mid-axillary line; and (c) behind the left 
margin of the sternum. Herpes zoster is frequently confused with 
this condition. The pain may last from one to several days, then 
gradually becomes less and less severe, and finally disappears. 
Frequently after its disappearance a feeling of soreness remains. 
Pleurisy wiJ:hout effusion is often confounded with intercostal 
neuralgia. A point of difference is that in intercostal neuralgia 
the pain increases when the patient bends over toward the affected 
side, while in pleurisy the pain decreases (Schepelman, 24b, p. 

Differential, Diagnosis Between Intercostal Neuralgia 
AND Pleurisy (Schepelman) 

intercostal neuralgia 

Character Sticking, burning or 

of Pain — lancinating — paroxys- 


Radiation Often to the inner side 

of Pain — of the arm. 

Location of Pain — In intercostal spaces. 

Pressure Points- 

Pressure — 

-(a) ISTear to the verte- 
bra at the back of 
origin of the inter- 
costal nerves. 

(b) Axillary line. 

(c) Sternal line. 
Touch and pressure are 

very painful on the 
affected nerves. 

DRY pleurisy 

Sticking and lanci- 
nating, but occurs 
on breathing. 


Over an infected area 
of the pleura. 

Over the infected 
area of the pleura. 

Painful over the area 
of the diseased 



Galvanization — Reduction of the pain. Xo change. 
Herpes — Often occurs. ISTone. 

Buhhing Sounds — Absent. Present. 

(Friction Fremi- 

. ^' i Xot so painful Very painful. 

Coughing — ( 

Sciatica. — ^By many sciatica is thought to be a neuritis, while 
others consider it a form of reference pain from some lesion, oc- 
curring along the course of the sciatic nerve. In some cases the 
sacroiliac joint becomes diseased ; and since the lumbo-sacral nerve 
passes over it, any disturbance of the joint will affect the nerve. 
Sometimes, also, a spicule of bone from an osteoarthritis of the 
spine may press on the nerve. Pressure by a tuberculous abscess 
will also cause this condition (Adams, 603). Sciatica often fol- 
lows a fall or an injury, and is the result of infections, consti- 
pation, sudden changes of temperature, etc. Women are less fre- 
quently affected than men, in the proportion of one to four. It 
is most frequent after the age of forty, and up to sixty years of 
age (Duckworth, 604) . 

The Pain. — The pain is constant, with severe paroxysms, 
which generally occur at night. At the time of the paroxysms 
the pain is sharp and lancinating. Between the paroxysms it is 
dull and aching. Frequently it comes on after exposure to cold, 
or following an injury. As a rule it does not last longer than a 
few months, though it may persist for a year. Because motion 
increases the pain, the patient tries to ease the weight on the 
affected side, and holds up the pelvis toward the sound side, thus 
flexing the trunk toward the diseased side and producing a static 

Location of the Pain. — The pain is felt principally in the 

back of the thigh, and runs diovm the leg, following the course of 

the sciatic nerve. Sometimes it is over the sacral or lumbar 

area. Frequently, on motion, pain is felt at the sciatic notch. 



The cause of this pain is the pressure of the nerve against the rim 
of the sciatic notch by the inflamed and contracting pyriformis 
muscle (Bashinger, 601). The tender points (Valleix's points, 

Fig. 56. — Cutaneous Disteibution Areas of the Small anb Greater 


SS= small sciatic; EP= external popliteal; PT = post tibial; S — sciatic; IS = 
internal saphenous; EP and PT are branches of the great sciatic. These 
drawings are composites from those given by Head and Thompson and 
represent the areas in which sensation was lost after division of their 
respective nerve supply, consequently they would also represent the 
areas in which pain would be felt in any painful lesion of the nerve. 
These areas correspond rather closely with those given by McKenzie (599). 

according to Edinger) are located: (1) over the anterior superior 
spine of the ilium; (2) in the center of the posterior surface of 
the thigh; (3) just inferior to the lower margin of the gluteus 
maximus; (4) in the middle of the calf of the leg; (5) under the 


head of the fibula; and (6) in the popliteal space. Dana also 
gives the back of the foot and the sciatic notch as points of ten- 
derness. In some cases the pain is referred, and it is found in 
the area of distribution of the sciatic nerve (see figure). Bruce 
(502, p. 511) advances an original claim when he states that 
sciatica is due to disease of the hip joint. He has found wasting 
of the gluteal muscles (59 per cent.) and obliteration of the 
gluteal folds (30 per cent.) in nearly all the cases which he has 
examined. Lameness was also most constantly present. Diag- 
nostic of sciatica is pain running up the back of the thigh when 
pressure is made on the posterior part of the knee with the leg 
extended a little more than a right angle (Dana, from Gowers). 
Kernig's sign is that hip motions are free as long as the knee is 
flexed, but become limited if the leg is straightened and flexion 
of the thigh is attempted. Sciatica should be diagnosed from 
hip-joint disease, disease of the cord (tumors of the cauda equina"). 

Fig. 57. — Method of Eliciting Pain in Sciatica. 

new growths (sarcoma), bone formations, etc. Gordon (608) 
reports two cases of tumor of the sacrum which had been mistaken 
for sciatica. Tabes has sometimes been mistaken fior sciatica, but 
the presence of the knee jerk in sciatica will exclude tabes. In 
relation to sciatica, Faber (616) mentions several cases, in which, 
in addition to the sciatica, there was also present a well-marked 
degree of adiposa dolorosa. After the reduction of the adipose 



tissue, the patients felt very much better. In cases of this kind, 
patients may have at the same time well-developed symptoms of 
both adiposa dolorosa and sciatica, and the one should not be 
treated to the exclusion of the other. In all cases of sciatica 
examine the pelvis carefully (per vagina and rectum) and the 
hip-joint both bimanually and by the X-ray. 

In Figure 57 is shown a method of eliciting pain in sciatica 
by making pressure on the nerve as it emerges from the sciatic 

Plantar I^buealgia. — Plantar neuralgia is due to a lesion 
of the plantar nerve, and anesthesia or paresthesia frequently ac- 
companies the pain. In the accom- 
panying figure the area of distribu- int. piantar i n s. 
tion of the nerve is outlined, and Ext. piantar iv. v 

L, IS. 

it is in this area that the pain 

Morton's neuralgia, due to pres- 
sure on the digital branch of the 
external plantar nerve, is found in 
early stages of flat-foot disease. 

In some cases of typhoid fever the 
toes become very tender. This, ac- 
cording to McCrae (607), is due to 
a local neuritis. It closely resembles 
a plantar neuralgia. The first com- 
plaint of the patient is of pain from 
pressure of the bed-clothes. 

Sacral or Lumbar-cord !N^eu- 
RALGiA. — Sacral or lumbar-cord neu- 
ralgia is betrayed by pain in practically the same regions as 
Head has outlined as the distribution areas of the different cord 
zones. In Kocher's fig-u'res the boundaries are, as a rule, held to 
be somewhat too high, the true areas in reality being one or two 
zones lower. 

It is useless to reiterate what has been said in regard to lumbar 
or sacral root neuralgia, because the symptoms are exactly similar 

Fig, 58. — Distribution of 
THE Plantar Nerves, 

The plantar nerves are branches 
of the tibial which is a 
branch of the sciatic (modi- 
fied from Cunningham's An- 
atomy; also from Gerrish's 
Anatomy) , 


to those found in brachial root neuralgia, to which the reader is 
referred. With this reference, and by the aid of the accompany- 
ing figures (Head zones; and Figs. 1889, 1890, Toldt),the reader 
should be able clearly to differentiate this condition. 

When a root or a root ganglion is involved, a continuous area 
of the skin is always affected, even though the fibers derived from 
this root unite with others to form a plexus. These regions of dis- 
tribution overlap so that when a root is diseased, sensation (epi- 
critic) is not completely destroyed over the entire area of the root 
distribution (Tigerstedt). It is entirely absent only in a central 
area. It increases gTadually toward the periphery until it be- 
comes normal in the areas of distribution of the unaffected roots. 
This border zone is not present, as a rule, for protopathic sensation. 
For this the cord zones seem to be more definitely marked. There 
is greater overlapping in the distribution of the nerve in the 
peripheral part of a limb than in the proximal part (Buzzard, 
"Brain," Vol. 25, p. 308). This is due to a spreading out of the 
nerve fibers in the periphery of the limb. These border areas 
react to a much gi'eater degree than normal to painful stimuli, but 
the strength of the stimulus to produce a reaction must be much 
greater than that applied to normal skin. 

In regard to loss of sensation, Head and Sherren say that ''it 
would seem that division (disease) of the posterior roots abolishes 
sensation to prick over an area larger and more sharply defined 
than that which becomes insensitive to light touch. Moreover, this 
insensibility to prick is accompanied by an inability to appreciate 
temperatures below 15° C. and above 60° C, although 40° C. 
and 23° C. may appear definitely warm and cool." In lesions 
of the peripheral nerves the opposite is the case, the epicritic sen- 
sation being lost in a larger area than is the protopathic ; i.e., the 
sensation to fine touch was absent in a larger area than was the 
sensation to prick (Head and Sherren, 244, pp. 310-311). Buz- 
zard (613), in a case of injury to the cord roots, found the sensi- 
bility to pain and temperature abolished, but the tactile sensibility 
partially retained. When sensation returns, the first to recover is 
the sensibility to prick, and to the more extreme degTees of heat 



and cold (Head and Sherren). In some cases lesions of the 
posterior roots are present, and sensations are lost without the 
patient being aware of their absence. 

When the posterior ganglia are affected, herpes generally ac- 
companies the neuralgia. When it is present, a copious eruption 
of vesicles appears over the affected area. These, when they dry 
up and desquamate, leave a brownish spot. The pain does not 
disappear upon the disappearance of the eruption, but may con- 
tinue for some time longer. A diagnostic sign of value in differ- 
entiating cord lesions from root or nerve lesions is the dissociation 
of sensation. When the cord is diseased, pain, touch, tempera- 
ture, etc., may be individually or collectively abolished; but in 
nerve lesions they are always collectively abolished (Sherren, 

The following is a differential diagnosis, compiled chiefly from 
Sherren : 

Coed LESIO^^. 
Loss of pain perception. 

Temperature sense is changed, 
so that (a) sensibility to heat 
may be abolished without any 
change in respect to the sensi- 
bility for cold (the inverse 
may be the case) ; (b) all dis- 
tinctions between the minor 
and extreme degrees of tem- 
perature are lost; and (c) 
"insensitiveness may be pres- 
ent to all forms of heat and 
cold, the lightest touch may 
be felt, and discrimination of 
the points of a pain may be 

Peripheral Lesiox. 

Pain produced by excessive 
pressure as long as there is 
any touch sensation. 

All sensations are affected, but 
not to the same extent, the 
epicritic being affected in a 
greater area than is the proto- 
pathic sensibility. 


Cord Lesion. 

Both superficial and deep toucli 
are usually unaffected, but 
when absent they usually dis- 
appear together. 

The patient may have touch sen- 
sation, but be unable to appre- 
ciate pain, heat and cold. 

Passive movement and position 
of the limb are not apparent 
to the patient. 

Spasticity of muscles on the 
same side below the level of 
the lesion. 

Paralysis and wasting of mus- 
cles at level of the lesion. 

Reflexes having origin below 
the level of the lesion are in- 

Pupillary reflex may be affected 
if the lesion is in the cervical 
cord, on account of affection 
of the cervical sympathetic. 

Muscle atrophy may not occur. 

Peripheral Lesion. 
Absent in a peripheral lesion. 

"Light touches over the distri- 
bution area with cotton wool 
are usually not appreciated, 
though deep touch and pres- 
sure evoke a response." 

Passive movements and position 
of the limb apparent. 

Wo spasticity. 

Paralysis of the muscles sup- 
plied by the affected nerve. 

Reflexes originating in the af- 
fected area are decreased. 

Pupillary reflex is not affected. 

Muscular atrophy of the muscles 
supplied by the affected nerve 
is always present 


The discussion of diseases of the central nervous system re- 
quires a recapitulation of the normal anatomical relations, which 
will be given, as briefly as possible, in the following paragraphs. 

1 Written by Dr. Alfred Neuman, Vienna. 


It will be entered upon here only so far as appears necessary for 
the understanding of the subject. 


The surface of the brain is supplied with furrows and convo- 
lutions, which, though of many varieties, show a certain regularity 
through which it is possible to differentiate them in every case. 
A few of them have special importance, and will be more minutely 

The central convolutions on the convex side of the brain, the 
paracentral lobe, and the median wall of the hemisphere with the 
adjacent part of the frontal lobe, represent the motor region. Far- 
thest below is the center for the facial and hypoglossus; in the 
middle is found the center or centers for the movements of the 
upper extremity; and in the uppermost third those for the move- 
ment of the lower extremity of the opposite side of the body. 
The centers innervating the musculature for the act of eating, 
for talking, for trunk movements, and for the closure of the 
eyes, are connected with the corresponding muscles of 
both sides, so that in case of a unilateral destruction of a 
center, the ability to perform these movements still per- 
sists. The speech center occupies the posterior part of the 
third frontal convolution, as well as the first temporal con- 
volution. In right-handed individuals it lies in the left hemi- 
sphere. In the third frontal convolution occurs the transforma- 
tion of ideas into words. The motor speech center in the tem- 
poral convolution is the seat for word sounds (sensory speech 
center). The centers for the sensation coming from the body lie, 
apparently, in the region of the motor centers, and, as it seems, 
are practically identical with them. However, the entire poste- 
rior central convolution,- as well as the parietal lobe, evidently be- 
longs to the sensory sphere. The centers for vision lie in the oc- 
cipital lobes, viz., in the fissure calcarina and in the cuneus, per- 
haps, also, in the neighboring adjacent portions of the lingual 
globe. The recollections of sensations of sight (the field for optic 
memory) are said to lie on the convexity of the occipital lobe. 


The olfactory center is supposed to lie in the gyrus hippocampus 
and uncinatus. The auditory center occupies the upper convolu- 
tions of the temporal lobe. From these centers, on the one hand, 
pass the centrifugally conducting fibers to the periphery; on the 
other hand the centripetal conducting fibers enter them. Of 
course, it is neither possible nor necessary to discuss all the con- 
ducting tracts ; only the two most important ones will be discussed 

Passing inward and downward from the motor centers, the. 
motor fibers are gathered in the posterior limb of the internal 
capsule, near the knee. They pass then into the brain peduncle, 
and from here the central portion passes through the pons into 
the medulla oblongata, where a part undergoes decussation and 
enters the lateral column of the spinal cord, from whence it goes 
over into the anterior roots of the peripheral nerves. The smaller 
part, non-decussated, descends in the anterior column of the spinal 
cord, and undergoes partial decussation farther below, and finally 
enters the anterior roots. 

The fibers for the motor nerves, which spring from regions 
lying adjacent to each other, run to the capsule in front of the 
pyramidal tract, decussate in the pons and in the medulla, and 
reach the corresponding nuclei. 

The course of the sensory conducting fibers is more complicated, 
but it shows in many respects a resemblance to that of the pyram- 
idal fibers. These sensory fibers, entering through the posterior 
roots, run for a part of the time (uncrossed) in the funiculus 
gracilis and cuneatus to their nuclei, also to the nucleus of the 
funiculus gracilis and the nucleus of the funiculi cuneati in the 
posterior surface of the fourth ventricle. From here they pass 
through the fibers of the arciformis internis, between the olives, 
to the opposite side (lemniscus decussation), which lies above the 
pyramidal decussation. One other part of the sensory fibers which 
ascends in the ground bundle of the anterior and lateral columns 
of the cord, and has previously crossed, joins with the first ones, 
after their crossing, and then again enters in common with them 
and passes through the crest of the peduncle to the brain cortex. 


on the way undergoing, in the optic thalamus, another interrup- 
tion hj relaying cells. Besides this, on the part of the lemniscus 
tract (the median), there is another portion, namely, the lateral 
lemniscus, which is composed of the fibers of the acousticus and 
the sensory fibers of the cranial nerves, and which lies more later- 
ally. It also arises in the upper half of the pons, out of a collec- 
tion of ganglia which communicate with the corresponding sensory 
cranial nerves, and passes, partly decussated, into the corpora 
quadrigemina, and from thence to the cortex. 

The pains which are due to diseases of the nervous system or 
its sheath are localized, on the one hand, in the head, in affections 
of the brain, and on the other hand in the back and the extremi- 
ties in diseases of the spinal cord. Exceptions to this general rule 
occur. Thus, there are pains radiating into the extremities in 
affections of the sensory tracts in the brain (Edinger) and head- 
ache in spinal-cord diseases (tabes, multiple sclerosis). Although 
these exceptions are not very frequent, yet we cannot attribute 
every headache to an affection of the brain substance, nor every 
back pain to an affection of the spinal cord. Both symptoms also 
belong to other diseased organs, and we are obliged to include in 
our discussion those forms of headache, or of pain in the back, 
which are caused by injuries which are indirectly elicited or pro- 
duced by changes in the substance of the central nervous system 
or their sheaths (through the circulation or by reflex means) ; for 
instance, headache in anemia, constipation, abnormalities, or in 
refractive errors of the eye. 


ISTow we should first ask ourselves where the sensations desig- 
nated as headaches arise, and in which tissue layer they are local- 
ized. It has been shown by clinical observations that both the 
brain substance and all its sheaths may be the seat of the pain; 
for instance, the outer skin, the aponeurotic layer of the cranial 
muscle, the skull with the periosteum, the meninges, and the brain ? 
itself. Concerning the membranes, it is seldom questioned that 
pains can originate therein ; indeed, frequently they have been 


considered as the only bearers of headache, since thej are supplied 
with cerebrospinal nerve fibers, which seem alone to be capable 
of pain conduction. The cortical origin of headaches, on the 
ground of the observations of Lenuander, would be declared im- 
possible, because of his observation, by operation, that the brain 
cortex may be sectioned without the patient feeling anything. 
Because of this, all intracranial headaches were attributed to 
irritation of the dura mater. Against this theory, Nothnagel ob- 
jected that the mechanical irritation employed on the brain was 
not sufficient to produce a reaction because another sort of irrita- 
tion (toxic, infectious) was needed to produce pain, as the head- 
aches from poisoning, infectious diseases, and anemia prove. L. R. 
Miiller remarks, further, that symptoms of loss of function which 
accompany migraine, as the shrinking of the field of vision, prove 
that certain parts of the brain are functionless for a short time. 
The observations of Oppenheim also speak in a very instructive 
way, opposing the view that only the dura mater can be looked 
upon as a source of pain, be it the result of direct or indirect irri- 
tation, through the intervention of brain pressure. 

Before it can be certain that pain which is felt as headache 
may arise in the brain substance itself, we must know the nerves 
which conduct these painful stimuli to the cortex. The only per- 
ipheral nerves known to be present in the brain are of the sympa- 
thetic system. If it could be shown that these fibers are able to 
carry stimuli in a centripetal direction, we would be justified in 
ascribing to the brain substance itself the power of originating 
painful stimuli. The circumstances are similar in regard to the 
sensibility of the abdominal organs. Here, also, are found nerves, 
which, only with the vagus or with the sympathetic, enter into 
the viscera. To both, only the motor functions were ascribed, and 
therefore it was concluded that the viscera possess no special sensi- 

However, it has been demonstrated that the sympathetic nerves 
carry sensory fibers which convey irritations from the viscera to 
the central nervous system (Xeuman) ; and this removes the most 
important objection to the acceptance of the idea that each organ 


possesses its own sensibility. The fact that the cerebral cortex is 
iilsensitive to the touch of the fingers, or of instruments, only goes 
to prove that it is insensitive save to these types of stimuli, which 
never occur normally. Just as the eye receptors act for light 
only, so there are probably receptors in the brain tissues which 
react only to special forms of stimuli. Just what these are is not 
as yet definitely known. The further conduction of the irritation 
may then be described as being through the rami communicans into 
the posterior roots and then through one of the above-described 
sensory tracts over the cord back again to the cortical brain sub- 
stance. The conduction of the painful irritation from the cover- 
ings in diseases of the meninges, of the cranium, of the aponeu- 
roses, or of the skin is over the trigeminus to the terminal cells of 
the same in the mid-braiu ; from there to the corpora quadrigemina, 
to the thalamus, and finally to the brain cortex ; in a similar way, 
by the upper cervical nerves through the median portion of the 
lemniscus (Edinger). 

Headache also appears as a symptom of disease of the brain 
substance and the meninges, and in diseases which certainly 
have nothing to do with these organs. As an example of the for- 
mer may be mentioned the headaches of brain tumor or of menin- 
gitis; as an example of the latter, the so-called rheumatic or indu- 
rative headache may be mentioned. I^ot only have we to con- 
sider diseases of an organic nature, but also those in which purely 
chemical substances cause molecular alterations, and thus, perhaps, 
cause headaches. Uremia, the different metal poisonings, or the 
infectious diseases are examples. Here, also, belong the headaches 
of anemia, of congestive states, and possibly of migraiiie.^ 

In a similar manner, also, in the headaches of neurasthenia 
or of hysteria, we must think of a hitherto undemonstrated change 
in the central nervous system. The elicitation of pain through 
mighty efforts, irritation or fright, as well as some accompanying 
disturbances (for instance, dizziness), can hardly permit of an- 
other explanation. 

If we would, with the help of headaches, try to arrive at a 

'This as yet has not been demonstrated. For another view, see pp. 189 and 190. 


diagnosis of diseases of the brain and its membranes, we must 
determine first whether they do not also occur in other dis- 
eases, and, second, whether they possess certain special peculiari- 
ties which would be characteristic of different diseases of the brain 
or of the brain membranes. Unfortunately, we have no such cri- 
teria. IsTeither are headaches limited to diseases of the central 
nervous system ; nor are they of as many forms as their causes are 
numerous. One can certainly say that there is no form of head- 
ache which would be pathognomonic for a certain disease, with the 
single exception, possibly, of a luetic headache. We must not per- 
mit ourselves, in making a diagnosis, to be giiided by the character 
of the headache alone, but must utilize the other symptoms. !N^ev- 
ertheless, in the character of the headache there are several pe- 
culiarities, which, if they do not speak for a certain disease, may 
still give a hint as to the nature of the trouble. Since, here, only 
those forms of head pain come into question which are connected, 
first of all, with diseases of the brain, or its membranes, all other 
kinds of pain belonging to the symptom complex of other diseases 
will be excluded. 

Should headache be present, we must, in our diagnostic in- 
vestigation, first search for disease of the outer coverings of the 
central organ ; that is, of the bony skull, of the aponeurotic layer, 
of the scalp muscle, and of the scalj) itself. These are treated in 
Chapter XIV. Should these be excluded the brain and its cover- 
ing should next be examined. 


Those diseases of the brain and the meninges in which head- 
ache forms an essential part of the symptom complex now will 
be described ; and in conclusion an analysis of these headaches will 
be given. 

First of all let us remember that not all pathological changes 
of the central nervous system are accompanied by painj and gross 
lesions of the brain are found (post mortem) without the patient 
having complained of headache. Therefore, an extensive dis- 
turbance of the brain may occur, as in cerebral hemorrhage, with- 


out the patient making any complaint. Even laceration may- 
occur so slowly that the patient either does not lose consciousness 
or does not at once become unconscious. The same is the case in 
brain-softening, in encephalitis, in infantile cerebral palsy, in 
general paresis, etc. Nevertheless, headaches are also found in 
the course of these diseases, either as a prodromal sign, as in 
hemorrhage, or in the later stages ; but they are not characteristic 
of the disease. 

In other diseases, however, headache forms an important symp- 
tom. Here must be included pachymeningitis interna, leptomen- 
ingitis, brain-abscess, brain tumor, aneurysm of brain arteries, 
syphilitic diseases of the brain and the meninges, migraine, neuras- 
thenia, hysteria, and circulation disturbances in the brain. We 
shall not discuss the latter. 

Pachymeningitis Interna Hsemorrhagica {Hematoma of the 
Dura Matter). — From a pathological, anatomical standpoint we 
have to deal with the formation of a fibrinous membrane on the 
inner surface of the dura mater, into which there occur from 
time to time smaller or larger hemorrhages. Headache may pre- 
cede or follow a developing coma, or, if there is no coma, the 
pain in the head may be the chief symptom of the disease. 
It may be associated with nausea and vomiting. Generally the 
pain is very intense. It may be felt as a circumscribed area, and 
then sensitiveness to percussion, circumscribed, unilateral, or dif- 
fuse, is present. When the hematoma is located on the convexity, 
the pain on the diseased side frequently predominates. When 
the hematoma is localized at the base of the skull trigeminal neu- 
ralgia occurs, with other symptoms due to pressure upon the 
cranial nerves. The remaining symptom-picture of pachymen- 
ingitis is not at all characteristic. The etiology (alcoholism, in- 
fectious diseases, trauma, general paresis, senility, lues, and blood 
diseases, pernicious anemia, leukemia and scorbutus) is, above all, 
important. In classic cases an irritative stage, with delirium, 
precedes, and this is followed by the attack with coma, during 
which signs of increased brain pressure can be demonstrated. 
There are slowing and irregularity of the pulse, changed breath- 


ing, vomiting, contracted, sluggish, or nonreacting pupils, choked 
disc, general cramps, bilateral deviation, etc. (see page 271). 

Symptoms which depend upon the location of the hemorrhage 
are hemiplegias, monoplegias, and unilateral and disseminated 
twitchings. The gradual increase and frequent change of the phe- 
nomena, with remissions and recurrences, are considered a charac- 
teristic. Hyperidrosis and elevation of temperature to 41° C. 
(105.4° F.) frequently occur. 

Leptomeningitis Purnlenta. — Here there is an infiltration of 
the pia mater, especially on the convexity. This is at first serous 
and later purulent. There is also a serous infiltration of the 
superficial layers of the cortex. In the tuberculous form a gela- 
tinous, rarely purulent exudate first spreads on the base between 
the brain and the peduncles and extends from here in all direc- 
tions, especially in the sulci, reaching a marked degree, however, 
only on the convexity. Headache is so characteristic in this dis- 
order that one should not make a positive diagnosis if headache 
is absent. It is extremely severe, mostly continuous, but pa- 
roxysmally increasing. The headache is, as a rule, located (by 
the patient) in the entire skull, sometimes more in the forehead 
or in the occiput. The patient manifests signs of pain, even in 
coma, in spite of the deepest stupor. He grasps his head, and at 
times cries out loudly, especially, however, if one tries to move 
the head. 

In tuberculous meningitis the pain in the beginning has a dif- 
ferent character. It occurs only temporarily, is not so great in 
intensity, and only later reaches the great severity just men- 
tioned. Gradually there appear disturbances of the consciousness, 
delirium, and eventually coma. Stiffness of the neck (the head 
being drawn backward), stiffness of the muscles of the back, and 
boat-like retraction of the belly occur. Hyperesthesia of the skin 
and the muscles^ restlessness, and jactitations are characteristic. 
JSTot uncommonly we find unilateral convulsions, and, less fre- 
quently, general ones. The patients conspicuously and rapidly 
become emaciated. In extensive involvement of the base of the 
brain, involvement of the cranial nerves occurs, the oculomotorius. 


the optic and also the acoustic being especially implicated. The 
fundus of the eye often shows the signs of neuritis. The tendon 
reflexes, which may be increased at first, are later usually lost, 
as are also the skin reflexes. Paralysis of the bladder and the 
rectum occurs only just preceding death. 

Chronic Anemia of the Brain (Chlorosis, Pernicious Anemia, 
Leukemia, etc.). — The headache in these diseases is usually not 
very severe, often consisting only in hyperesthesia of the head. 
It can be recognized, sometimes, by the fact that it grows worse 
when the patient is in an upright position, and decreases when 
he lies down. Other signs due to anemia of the brain are the 
occurrence of fatigue, both mental and physical, after a small 
amount of work. Drowsiness, humming in the ears, stars before 
the eyes, vertigo, and an apathetic state may be present. All 
these conditions improve when the patient lies down (see page 

Hyperemia of the Brain. — Congestions which consist of a sud- 
den afilux of blood to the head cause pressure and sometimes 
pain, which increases with the pulse beat. Other symptoms con- 
sist of a feeling of heat, of throbbing in the face, vertigo, and 
disturbance of consciousness. These attacks, however, usually 
last only for a few minutes, sometimes an hour, and, in rare 
cases, several hours. The headache in venous congestions of the 
brain, ear lesions, struma, etc., is made worse by coughing and 
sneezing, as well as by the patient assuming the horizontal posi- 
tion, especially with the head drooping. The rest of the symp- 
toms are not unlike those in chronic anemia, i.e., apathy, drowsi- 
ness, vertigo, and slight mental confusion. 

Brain abscess originates from a suppuration transmitted from 
the skull. It may be of traumatic or otitic origin, or may arise 
from remote organs. In regard to the latter, a lung abscess, lung 
gangrene, or a pyemia may form the primary starting point. 
Headache is one of the earliest and most constant symptoms of 
brain abscess. It increases, especially during the development 
and the growth of the pus focus, to such a high degree that the 
patient constantly groans and behaves like a maniac. In the latent 


stage the pain may be slight. These paroxysms of pain often last 
only for a few hours ; sometimes, however, they persist for days. 
The pain is of a boring, throbbing character, mostly dull, either 
spread over the whole head, or is more severe on one side, prin- 
cipally on that which is the seat of the abscess. However, the 
localization of the pain does not always correspond to that of the 
focus. An abscess of the cerebellum, for instance, may cause 
frontal headache. A circumscribed area of sensitiveness, on per- 
cussion, furnishes a much more important clew to the localization 
of the focus. Coughing, sneezing, stooping, as well as fever, 
make the headache worse. Other symptoms of brain abscess due 
to the suppuration, are elevation of temperature, w^hich does not 
show any characteristic course, and the not very infrequent chill. 
Retardation or irregularity of the pulse, changed breathing, optic 
neuritis (which occurs here more frequently than choked disc, 
and, indeed, more frequently on the same side as the focus), gen- 
eral convulsions and mental disturbances, chiefly in form of 
stupor, depression, delirium, and eventually coma are later symp- 
toms. Rapid emaciation is often very conspicuous. 

Brain Tumor. — Headache is one of the most frequent signs 
of this disease. In accordance with the gradual growth of the 
tumor, the pain is moderate in the beginning and variable in its 
intensity. Later it becomes very severe, but still shows exacer- 
bations, which occur generally in the morning. They may be 
partly spontaneous, and partly due to an increase of blood pres- 
sure from pressing, coughing, sneezing, stooping, etc. During 
such paroxysms the patient may either lie in bed, groaning, often 
perfectly apathetic, or he may run about in the room, pushing 
and knocking his head against the wall, and behaving like a. 
maniac. Stupor that occurs in the later stage dims the severity ; 
yet even then one observes that the expression of the face is dis- 
torted, and the seizing of the head by the hands proves the con- 
tinuance of pain. The pain is, as a rule, diffused over the entire 
head; sometimes it is unilateral, more in the occipital, or more 
in the frontal region. Sometimes the localization depends upon 
the position of the tumor, as tumors of the posterior cranial fossa. 


for the most part, cause occipital headache, which may radiate 
into the shoulders. One must, however, not depend upon this 
entirely. More stress should be laid upon the circumscribed 
sensitiveness on percussion, which, however, does not regularly 
occur, but only when the tumor lies quite superficial. 

Trigeminal neuralgia, especially of the first branch, is ob- 
served in tumors of the chiasma, cerebello-pontine angle, and pons, 
and may later be followed by loss of function of the nerve. Signs 
of pressure on the optic nerve are rarely lacking. Papilledema 
(choked disc) is seldom missed. It may be absent in tumors of 
the central convolutions, and of the first and second frontal con- 
volutions, but it is almost never present when foci are in the pons. 
Otherwise, however, choked disc, or its forerunner, optic neuritis, 
is one of the cardinal symptoms. It is mostly double sided, fre- 
quently more intense on the affected side. ISTot less important are 
the changes of intelligence and of the psyche. The patients think, 
speak and act more heavily. Soon they become stupid and drowsy. 
They fall asleep while they are still speaking, or in the midst of 
a meal. At such times they pass feces and urine involuntarily. 
Delusional ideas, ideas of persecution, and finally delirium may 
be present. Very frequently vomiting (of a cerebral type) oc- 
curs, with retardation of the pulse, which may here assume a high 
degree, and, after some time, usually passes into pulse accelera- 
tion (vagus paralysis). Giddiness is frequently complained of. 
It has not, however, been accompanied by rotatory nystagmus, 
which occurs principally in tumors of the cerebellum. Convul- 
sions and loss of consciousness occur paroxysmally, together or 
separately. Parallel with these general symptoms are the so- 
called focal symptoms. By direct focal symptoms we mean those 
phenomena which are the result of pressure on that area of the 
brain in which the new growth develops. 

Focal Symptoms of the Motor Region. — Here are found 
the results of irritation, paresthesias and spasms, which are fol- 
lowed later by paralysis. These three phenomena generally begin 
in one particular place, and then spread over the neighboring 
areas, for the most part in regular order (Jacksonian fits). The 


order in which the individual groups are affected is a regular 
one, and extends .from center to center, beginning, for instance, 
in the right foot, and extending to the knee, hip, shoulder, elbow, 
hand, and distribution area of the facial nerve. Consciousness 
is intact, at first, and only later becomes cloudy in attacks of 
greater intensity and longer duration. Correct observation of the 
muscle groups initially involved is of importance for the localiza- 
tion of the tumor. 

As a sequence of such a spasmodic seizure, but also unaccom- 
panied by a seizure, paralyses arise, which, in the beginning, are 
transient, but which later become permanent, and attack (like 
cortical epilepsy), little by little, wider areas, imtil finally they 
present the complete picture of a hemiplegia, with all its char- 
acteristics, namely, increase of the tendon reflexes, spasms, ab- 
sence of skin reflexes, Babinski, clonus, etc. 

TuMOES OF THE FKONTAL LOBE producc motor aphasia if they 
lie in the left inferior frontal convolution. In tumors of the left 
second frontal convolution one sometimes sees, as a result of 
the disturbances of the innervation of the muscles of the buttock, 
uncertainty in walking and standing, and in turning toward the 
crossed side. As a remote effect upon the motor region, Jack- 
sonian epilepsy may occur. When the tumor lies in the temporal 
lobe, disturbances of hearing, such as buzzing and whistling, may 
occur. There may, also, be disturbances of smell and taste. 
Finally, tumors of the left first temporal convolution produce 
word-deafness, memory aphasia and paraphasia. Here, as a dis- 
tant result, are observed Jacksonian epilepsy; and further, from 
the action on the occipital lobe, crossed hemianopsia, hemianes- 
thesia, and hemiplegia. 

Tumors of the parietal lobe give rise to little that is char- 
acteristic (disturbances of muscle sense, crossed hemiataxia). In 
fact, as a rule, they produce only distant effects, by pressure 
upon the motor region (Jacksonian spasms), or on the occipital 
(hemianopsia), etc. 

Still more uncertain is the diagnosis of tumoes of the cor- 
pus CALLosuM, which, according to Ziehen, have paraparesis as 


the only sign of any value. Apraxia is often present in tumors of 
this region. 

TuMOEs OF THE CENTKAL GANGLION characterize themselves 
by disturbance of the inner capsule. Therefore, they cause hemi- 
plegia, which gradually arises if more of the anterior part of 
the capsule is affected, and hemianesthesia if more of the posterior 
part is affected. Hemichoreas, hemianesthesise, and unilateral 
tremors may result. 

When the corpora quadrigemina are the seat of the tumor, 
sight disturbances, hearing disturbances, and double-sided 
paralysis of the eye muscles of a muscular character form the 
clinical picture. With the disease, also, come disturbances of 
equilibrium on walking and on standing. 

Tumors of the pedunculi cerebri produce paralysis of the 
oculomotor of the same side, and of the extremities of the oppo- 
site side (hemiplegia alterans superior), oculomotor paralysis, 
with tremor, similar to that in paralysis agitans. 

If the CEREBELLUM is the seat of the tumor, this can be 
recognized, in most cases, by a few important signs. The most 
characteristic is cerebellar ataxia. The patient sways from one 
side to the other. Frequently, also, he complains of a genuine 
dizziness, in which objects seem to be moving around him, espe- 
cially upon sitting up. With this dizziness nystagmus is fre- 
quently combined. Vomiting is very common. It is also an im- 
portant symptom that the headache is localized, especially in the 
occipital region, possible in the nape of the neck, and that the 
choked disc, which is mostly bilateral, is seldom absent. Along 
with this are opisthotonic and tetanic contraction of the muscula- 
ture of the neck. As indirect local symptoms, the affections of the 
different cranial nerves, of the pyramidal tract (paraparesis, 
crossed hemiparesis, intentional tremor) and also the occurrence 
of hydrocephalus interna" must be considered. 

Tumors of the pons show slight development of general 
symptoms, and the absence of a choked disc almost as the rule. 
The most classic symptom is the hemiplegia alterans inferior. 
There is paralysis of the extremities of one side, with paralysis 


of the facial, trigeminus, or abducens, of the other side, in which 
case, of course, all three of the above-mentioned cranial nerves 
may be affected. Very frequently, before the paralysis, very 
severe attacks of trigeminal neuralgia occur. Further, associated 
eye-muscle paralysis of the right rectus internus on the side of 
the tumor must be mentioned; also in right-sided paralysis there 
is a. simultaneous disturbance of hearing, through pressure on the 
acoustic nerve at its place of origin. 

TuMOKS OF THE MEDULLA may run a symptomless course, but 
when they produce symj)toms they are similar to those of tumors 
of the pons, with the exception that they injure deeper-lying 
cranial nerves, namely, the eighth and twelfth, causing disturb- 
ances of hearing, speech and deglutition, as well as paralysis of 
the extremity on the other side, singultus, diabetes insipidus, 
breathing changes, etc. 

If the tumor is seated in the third ventkicle^ drowsiness 
and change of intelligence are usually prominent. 

Tumors of the base of the brain give rise to few general 
symptoms. According to Oppenheim, choked disc and vomiting 
frequently fail. Pain, on pressure, occurs in the bones which are 
in relation to the base of the brain. Bleeding from the nose and 
pharyngeal cavities also occurs ; and, above all, is to be considered 
the involvement of brain nerves in a certain combination corre- 
sponding to their topographical arrangement. 

Tumors of the hypophysis also produce few general symp- 
toms. Here, also, choked disc is frequently absent, and headache 
may be very slight. On the other hand, the eye symptoms (bi- 
temporal hemianopsia, amaurosis, eye-muscle paralysis, exoph- 
thalmos) and certain disturbances in development (hypoplasia of. 
the genitalia, feminine habitus), as well as adipositus universalis 
and myxedematous skin, form the most striking symptoms. 

Tumors of the posterior cranial fossa often begin with 
humming in the ears, difficult hearing and disturbances of equi- 
librium. Associated with these is irritation or paralysis of the 
trigeminus, with absence of the corneal reflex (Oppenheim). In 
relation to this, as a result of the pressure on the surrounding 


region, cerebellar ataxia, nystagmus and sight paralysis (Oppen- 
heim) occur. The patient complains of occipital and frontal 
headache and vomiting. Objectively, one very frequently finds 
choked disc and localized sensibility on percussion. 

Aneurysm of the Brain Arteries. — Here the headache is also 
one of the general symptoms. It is generally described as throb- 
bing, and may be half-sided, as in hemicrania, diffuse, or be felt 
more in the occiput (in aneurysm of the basilar artery). Vomit- 
ing, dizjziness and stupor (corresponding to the reduction of brain 
space) are present, while, on the contrary, choked disc is infre- 
quent. A pulsating vessel murmur, heard over the skull, is con- 
sidered an especially characteristic symptom. However, this is 
found in other diseases, and also in normal children. The develop- 
ment of the process is often very rapid. The localization is to be 
inferred from the local symptoms. 

Parasites of the Brain (Cysticercus Cerebri). — Headache^ 
with dizziness, is a frequent symptom ; but the characteristic 
signs are localized attacks of cramps, due to the location of the 
cysticercus in a circumscribed area of the motor region. At- 
tacks of an epileptiform character, with psychic disturbances (im- 
becility, confusion, irritability), are present. The local symp- 
toms differ according to the seat of the parasite. Frequently 
there is a conspicuous change in the intensity of the clinical 
symptoms. A cysticercus tumor may be diagnosed if the possi- 
bility of infection has existed (association with infected individ- 
uals, ingestion of raw pork, etc.), or if the cysticerci are found in 
another portion of the body.- The echinococcus also produces 
tumor phenomena. However, it is very seldom that one can suc- 
cessfully diagnose it, since, in order to do this, an echinococcus 
cyst must be found somewhere else in the body. 

Hydrocephalus Internus. — Headache, in this case, is usually 
constant. For the rest, the disease picture is similar to that of 
meningitis purulenta, with the exceptions that the fever is not so 
high, the headache is less severe, and frequently a perfect cure 
occurs, with sequelae of eye disturbances. The differentiation is 
easiest made through spinal puncture. Chronic hydrocephalus 


progresses, in most instances, under the symptom-complex of a 
brain tumor, or a tumor of the cerebellum. According to Oppen- 
heim, two points for the differential diagnosis are to be taken 
into consideration: (1) whether there exists a deficient congenital 
development (abnormal size and form of the skull) ; and (2) the 
occurrence of remissions or of intermissions of a month's or of a 
year's duration. 

Syphilis of the Brain. — Anatomically the process consists 
either in the formation of tumor-like gummata or in changes of 
the vessel walls, especially of the basilar artery. A tubercular 
basilar, gummatous meningitis, starting in the region of the 
chiasm, is even more frequent. Headache is one of the earliest 
symptoms. It may occur months or years before other signs. 
ISTightly exacerbations, recurring at a certain hour, and disappear- 
ing at a certain time, are characteristic. During the exacerbation 
the patient suffers considerably by reason of the severity of the 
pains. In the intervals, however, the pain is bearable. It is 
mostly felt as a diffuse pain, situated deep within the skull- 
Sometimes it has a circumscribed border, if the process reaches 
the convexity. In these cases, also, a circumscribed percussion 
sensibility may be present. Other constitutional symptoms be- 
long to the picture of cerebral lues ; for instance, vomiting, dizzi- 
ness, attacks of unconsciousness, psychic disturbances, dementia, 
stupor and states of irritability occur in a paroxysmal manner, 
alternating with periods of normal consciousness. In addition to 
these, there is paresis or paralysis of the cranial nerves, especially 
the optic, and oculomotor-ptosis is especially frequent. Any of the 
other cranial nerves may be involved in differing combinations. 
The repeated change in the intensity and the final complete dis- 
appearance of all the symptoms are typical. The onset of hemi- 
plegia, which develops in the course of one or two days without 
disturbances of consciousness, is a frequent symptom. 

Hysteria. — The headache, frequently felt as a dull pressure 
in the entire area of the skull, may often be localized to a cir- 
cumscribed place on the vortex, in the occiput, or in the temple. 
It is^ as a rule, associated with hyperesthesia of the scalp, so that 


the slightest touch or the least disturbance of the hair causes a 
pain which increases on pressure. Bodily and mental exertion 
and emotion may also produce increased irritation. The condition 
is improved by diverting occupations and during quiet and dark- 
ness. It may last for hours, days or months, and does not leave 
the patient even during sleep. The remaining hysterical symp- 
toms are of so many forms that they cannot briefly be given here. 

Neurasthenia. — Here, also, the intensity of the headache is 
not very great. It appears mostly as pressure and constriction 
of the entire head, the feeling often being strongest in the region 
of the forehead, and not seldom in the occiput. The patient also 
complains of a contraction, as though the head were bound with 
an iron band. The headache of neurasthenia is also produced or 
increased through great bodily or psychic irritation, or by emo- 

Hemicranic Headache (Migraine). — The real attack of 
headache is often preceded by symptoms which bear a certain re- 
lationshij^ to it. Some patients, previous to the attack, feel lan- 
guid, exhausted, and are without appetite, or, on the contrary, 
manifest great hunger. As aura, Moebius designates certain 
paresthesias, which may or may not precede the attack, namely, 
eye symptoms, flying bodies, glittering, narrowing of the field of 
vision (especially hemianoptic), and glistening scotomata; these 
may occur, for instance, as a light point in one or both eyes, which 
is diffused or travels across the field of vision in a zigzag line. 
Other forms of the aura are unilateral paresthesia, aphasia, con- 
fusion, states of anxiety, etc. ■ The attack itself consists in head- 
ache of the severest degree. Generally it occurs after waking, 
with slight intensity, and gradually increases to an unbearable 
degree. It lasts for a few hours to a few days. Frequently it 
stops during sleep. There are patients in whom migraine attacks 
are of slight severity, and in whom light and severe paroxysms 
interchange. In the intervals, which may last for weeks and 
months, the patient feels perfectly well. The pain is mostly 
one-sided, but is also double-sided, usually in the forehead and 
eye region. Less frequently the occipital region is attacked. As 


a rule, the pain is located by the patient as deep in the skull, 
and' is of a boring or tearing character. The patient may say he 
feels as though his head were in a vise, as though it were bursting 
asunder, or as though it were being belabored with a hammer. 
The countenance of the patient during the attack is, in most 
cases, pale, although in some instances the face and conjunctiva 
are reddened. During the attack, also, the patient is very sensi- 
tive to all forms of stimuli. JSToises, smells and lights increase 
the pain. ITausea and vomiting sometimes are accompanying 
symptoms, and, in most cases, the attack concludes with them. 



The character of the headache alone rarely permits an accu- 
rate diagnosis to be made. Yet each and every one of the cranial 
lesions enumerated have some features which predominate 
more or less. Thus, in cerebral lues, our attention is drawn to 
the night attacks. This is rare in other forms of brain disorder. 

Intensity. — The intensity of the pain varies greatly in dif- 
ferent cases. The severest degrees of headache are most frequently 
observed in leptomeningitis, then in brain-tumors, in abscess, 
brain-syphilis and hemicrania. Tolerable, though still severe, 
headache is found in pachymeningitis hsemorrhagica interna, in 
some forms of headache in hysteria, and in aneurysm of the basilar 
artery. Headache due to neurasthenia and disturbances in the 
circulation of the brain is naturally not very severe. In the 
first-named group of cases (pachymeningitis interna hsemorrhag- 
ica) paroxysmal exacerbations occur, giving rise to very con- 
spicuous manifestations of pain. The patient groans, whines, 
and either shows dull apathy or jumps out of bed, runs about 
and presses his head. Pain of this severity, however, is only 
temporary, and the very manner of its occurrence, as well as the 
character of the free intervals, is important for the diagnosis in 
some cases. 

It has been noted that the paroxysms of pain in cerebral syph- 
ilis may be expected with great probability during the night. 


The pain appears at a certain hour after the patient has gone to 
bed, usually at the same hour every night. In the periods be- 
tween the paroxysms the headache is either of little intensity or 
disappears entirely. 

The typical form of hemicrania is also characterized by its 
paroxysmal occurrence. After an aura of short duration, or 
perhaps without an aura, there appears the most severe pain, 
compelling the patient to lie down and keep absolutely quiet. 
Usually sleep puts an end to the attack, but frequently the pain 
appears in the morning after awaking. In this point, therefore, 
the pain differs from that in lues cerebri. Another feature may 
be used for the diagnosis of hemicrania, namely, that the pauses 
between paroxysms, which may last for days, weeks, even months, 
are perfectly free of pain. During these periods the patient feels 
absolutely well. 

Paroxysmal exacerbations occur in other affections ; for in- 
stance, purulent leptomeningitis, abscess, tumor, etc. These exac- 
erbations, however, appear irregularly, and the periods between 
the paroxysms are by no means free from pain. It is important 
to know that in cases of brain abscess the paroxysmal exacerba- 
tions of the headache appear usually during the development and 
growth of the pus foci; and, obviously, for this reason they are 
frequently connected with fever-elevations. 

Between the varieties of headache characterized by their great 
intensity and the headache which is described by the patient as 
hyperesthesia of the head (pressure or heaviness) there are 
scarcely any intermediate forms. The latter sort of headache is 
seen in neurasthenia, hysteria, and disturbances of circulation in 
the brain. It is characterized in most cases by its continuous 
course; although variations in intensity may occur, they do not 
show any feature characteristic of the condition. In most cases 
direct spontaneous paroxysms of pain do not occur, neither are 
there any periods perfectly free from pain; yet the feeling of 
pressure in the head does not leave the patient, even in his sleep. 

Moderate degrees of headache occur in pachymeningitis in- 
terna, prior to, or after a comatose attack, and also without any 


coma. Here, also, there are intermissions of pain of varying 
duration, which cease on the onset of another bleeding. The 
headache in aneurysm and the paroxysms of headache in hysteria, 
which, as a rule, occur in the parietal region, are somewhat simi- 
lar to those in pachymeningitis, so far as their intensity is con- 

Localization of Pain. — Localization gives hut few clews for 
diagnosis. True, there are diffuse headaches, unilateral headaches, 
headaches involving only the frontal region, as well as those of the 
occipital region. Finally a headache may have a circumscribed 
area; but there is scarcely one of those localizations which might 
be looked upon as characteristic of any definite affection. 'Not 
infrequently one finds all of these localizations involved in one 
and the same disorder. This may be the case in a brain tumor, 
for instance. ^Nevertheless, some affections predilect a certain 
region of the cranium. We know, for instance, that in migraine 
headache occurs most frequently unilaterally. Moebius states that 
among patients of his from whom he could obtain reliable state- 
ments fifty-seven had almost constantly unilateral headache, 
whereas twenty-five declared that they had felt it on both sides. 
Moebius doubts the reliability of the second statement. On the 
other hand, there are diseases in which unilateral headache is, 
comparatively speaking, seldom present ; for instance, in leptomen- 
ingitis, neurasthenia and in disturbance of the cerebral circulation. 
Frontal headache is observed in neurasthenia comparatively fre- 
quently, and the unilateral headache in migraine is often most in- 
tensely felt in or behind the eye. Pressure in the parietal region 
is frequently met with in hysteria, is mostly circumscribed and 
is accompanied by sensitiveness on pressure. In a comparatively 
large number of diseases the painful area is sharply circumscribed, 
a fact often noted in pachymeningitis, in brain abscess and in 
cerebral syphilis. This circumscribed pain is generally, also, 
associated with a circumscribed sensitiveness on pressure (the so- 
called sensitiveness on percussion). 

The tension of the pain helps less frequently than its localiza- 
tion in making a diagnosis. Certainly even here the greatest 


caution is necessary; for cases in which a tumor in the occipital 
region causes frontal headache are by no means rare ; and it also 
happens that a tumor of the left side may give rise to pain felt 
in the right half of the cranium. If, however, a pain is con- 
stantly felt in one place, or, when generally diffused, it originates 
from one place, no mistake will be made if one locates the cause 
of the disease, be it a tumor or an abscess, in that region. Pain 
in the occiput or neck, radiating into the back, justifies one in 
assuming that the focus lies below the tentorium. We may as- 
sume, with great probability, that a lesion exists in the same 
area in which pain is present, if we have to deal with a pain con- 
stantly confined to one side, or to the frontal region. Of course 
one should strictly avoid depending upon pain, alone, in forming 
conclusions. To form a diagnosis, which often implies a great 
responsibility, all the other observations and examinations (which 
will be discussed later) must be resorted to. 

Character of the Pain. — The character of the headache tells 
us very little concerning its cause. Patients describe various 
kinds of headache in quite different ways, most frequently as 
dull, pressing, drawing, cutting, lancinating, constricting, driving 
asunder, roaring, pulsating, and throbbing. Since every form 
may occur, in very different intensities, there result an exceed- 
ingly large number which are of only very little value for the 
diagnosis. If there is a kind of headache to which we may 
ascribe a characteristic feature, it is the pulsating and throbbing 
variety. It is found most clearly pronounced in an aneurysm of 
the cerebral vessels, but also in hyperemia, and sometimes in 
cases of abscess. 

A knowledge of those external influences which may cause 
an exacerbation of an already existing headache, or which are 
capable of producing headache, is more important for the diag- 
nosis than are the location and the character of the pain. It has 
been emphasized that, in those affections in which the sensitive 
area is circumscribed, an increase of the headache can be brought 
about on pressure, with the finger, or by striking with the j)ercus- 
sion hammer. These affections are pachymeningitis, brain abscess, 


cerebral syphilis and hysteria. There are other cases in which 
the headache grows considerably worse by the increase of 
internal brain pressure, such as occurs in coughing, sneezing, 
pressing, stooijing. This is the case in brain abscess, brain 
tumor, and passive congestion. Sometimes movement of 
the head increases the headache, especially in meningitis and 

In the latter, according to Moebius, movements of the eye 
have a much more unfavorable effect than those of the whole head. 
The upright position of the body has an unfavorable influence 
upon anemic headache, whereas horizontal position increases an 
hyperemic headache. Headache due to abscess, tumor and hemi- 
crania may be increased by alcoholism. In conclusion, it may be 
added that mental exertions and emotions are able to elicit and 
to increase headache in neurasthenia, hysteria and hemicrania, 
and the same factors may aggravate the headache in case of 

Influence of Therapy. — Diverting occupation, eating, and 
rest influence headache in a favorable way, especially nervous and 
hysterical headache. According to Moebius, however, they may 
alleviate, also, less severe attacks of migraine. This latter often 
may be cured or alleviated, without any other treatment, by 
removal of irritants (light, noise, etc.). 

By the observation of these circumstances, it will often be 
possible to draw, from the character of the headache, a conclusion 
as to its cause. A severe pain, for instance, which appears 
paroxysmally on one side, and which is favorably influenced by 
rest and ends with vomiting, may be looked upon with great prob- 
ability as hemicrania ; nightly exacerbations point to cerebral lues, 
whereas headache that occupies the cortex makes us think first of 
hysteria. It is not the task of the diagnostician, however, to 
make the diagnosis from one single symptom, but eventually he 
will utilize, in making the diagnosis, all the signs of the disease. 
In the following lines, therefore, we will discuss all those factors 
by which the individual affections of the brain and spinal cord 
may be differentiated ; and for the sake of completeness those 


affections will be discussed here which are not accompanied by 



Brain Abscess. — If the analysis of the pain has shown that 
we have to deal with a brain abscess, the following conditions 
will come into consideration for the differential diagnosis : 

Bkain Tumoe. — Against this would speak the etiology (with 
the exception of traumatism, which also may cause a tumor), 
the fever, the chills, and the comparatively more rapid course 
(weeks to months). A well-marked, choked disc (optic neuritis 
occurs also in an abscess), as well as the better-marked phenomena 
of pressure, in general, would indicate tumor. 

Leptomeningitis Pueulenta.-— This takes a course even 
more rapid than abscess — days and weeks. It shows high fever 
and acceleration of the pulse (in case of abscess only low grades 
are observed), hyperesthesia of the organs of sense, of the skin 
and muscles, involvement of the cranial nerves, scaphoid retrac- 
tion of the abdomen, and rigidity of the muscles ; whereas optic 
neuritis, retardation of the pulse, less stupor and a negative result 
of lumbar puncture, i.e., a clear puncture-fluid, rather speak in 
favor of a diagTiosis of brain abscess. 

Leptomeningitis Seeosa. — This occurs either as a primary 
affection, or as an accompanying symptom of an otitis media. 
It may heal spontaneously. In addition to this, the greater fre- 
quency of a choked disc and of disturbances of sight would speak 
against brain abscess. 

Otitis Media. — This may cause diagnostic difficulties by the 
occurrence of cerebral symptoms, but can be recognized by the 
disappearance of the latter on removal of the pus. 

ExTEADUEAL Abscess {In Sequeuce to a Suppuration of the 
Ear). — This is indicated by the presence of focal symp- 
toms and the absence of local signs, i.e., the absence of 
the inflammatory swelling and painfulness in the region of the 
mastoid process. 

Sinus Theombosis. — Here are found, in contradistinction to 
brain abscess, pyemic fever and acceleration of the pulse, com- 


plete absence of any disturbance of consciousness, more frequent 
occurrence of choked disc, and externally a thrombosis of the 
jugular vein in the neck. On the other hand, focal symptoms 
speak for the presence of an abscess. 

Hemoekhages into the Meninges.— When caused by trau- 
matism, they proceed without any fever, and follow directly after 
the injury. 

Migraine. — Against it speak both etiology and absence of 

Teaumatic ITeueoses^ Hysteeia and ITeueasthenia. — . 
They may occur as concomitant symptoms of a brain syndrome, 
or may be independent affections, and only simulate these. 

Beain Syphilis.- — This is mostly accompanied by the loss of 
pupillary reaction to light, and can be surely diagnosed by the 
positive result of Wassermann's reaction and of antiluetic treat- 

Leptomeningitis. — In the differential diagnosis of leptomenin- 
gitis quite a number of diseases come into consideration in which 
focal symptoms always decide in favor of meningitis. 

Pneumonia^ Typhoid Fevee and Pyemia. — Rusty sputum 
and dullness over the lungs speak for pneumonia; gradual devel- 
opment and the positive result of Gruber-Widal's reaction speak 
for typhoid fever ; retardation of the pulse, stiff neck and paraly- 
sis of the cranial nerves, as well as the intense headache, continu- 
ing also during the coma, speak for meningitis ; frequent chills, 
skin and rectal bleeding, and joint swelling speak for pyemic 

Beain hemoeehages^ embolus and theombosis, as well as 
ENCEPHALITIS H^MOEEHAGicA ncvcr causc fcver-elcvations of 
such a duration as seen in meningitis. 

Otitis media is confused with meningitis principally because 
the ear trouble is followed by a serous leptomeningitis. As such 
a serous meningitis often can be differentiated from a purulent 
one only with difficulty, a differential diagnosis can be made in 
most cases only by the disappearance of the meningeal symptoms 
after the evacuation of the otitic focus. 


In uremia, albumin and formed elements, as a rule, are 
found in the urine. 

The SEROUS form of meningitis is, as above mentioned, diffi- 
cult to differentiate from the purulent form. In most cases the 
fever is less. 

Delirium Tremens. — Stiff neck and the extremely severe 
headache speak against it. 

Tuberculous meningitis occurs in early childhood (2 to 14 
years). It does not set in in such an abrupt manner, and shows 
frequent remissions (of temperature, stupor, etc.). 

In children the stomach and intestinal disturbances may 
cause symptoms similar to those of leptomeningitis, and may give 
rise to confusion in diagnosis. However, the influence of the diet 
and the action of a j)urgative will soon clear the diagnosis. 

Brain Tumor.— Hysteria may be differentiated by its head- 
ache, spasmodic attacks and hemiplegic paralysis. Choked disc 
and focal symptoms will guide us here, but it must not be for- 
gotten that both affections may occur together. The possibility 
of influencing the condition psychically speaks for hysteria. In 
case of a tumor we find also, during the acme of the pain, retarda- 
tion of the pulse and vomiting. These are found in hysterical 
headache, only when it occurs on one side. 

Concerning migraine^ which might give rise to confusion by 
the severity of the headache and vomiting, we must be guided by 
the history (heredity in migraine) and by the presence of choked 
disc and focal symptoms in tumor of the brain. 

Paresis often comes into review in the diagnosis of brain 
tumor. The clinical symptoms may be very similar. A positive 
Wassermann, a positive cell count, and a positive globulin reac- 
tion almost certainly speak for paresis and against a brain tumor. 
In paresis choked discs are not frequent. The attacks of cortical 
epilepsy occurring in both, and which in the external manifesta- 
tions are similar, usually leave little permanent palsy in paresis. 

Multiple sclerosis comes into consideration in affections of 
the cerebellum, of the pons, and of the corpora quadrigemina, 
which likewise produce intention tremors, nystagmus, spastic 


ataxia, as well as paretic symptoms in the extremities. To these 
must be added the occurrence of atrophy of the optic nerve, if 
they are accompanied by brain symptoms. However, the general 
symptoms of the tumor, such as severe, continuous headache, the 
retardation of the pulse, vomiting and stupor, do not belong to the 
clinical picture of multiple sclerosis. In epilepsy, which has a 
certain similarity to tumor in its paroxysmal character, the gen- 
eral symptoms will facilitate the differential diagnosis. 

Pachymeningitis Haemorrhagica Interna. — Differential diag- 
nostic points speaking against pachymeningitis are either the en- 
tire absence of stiff neck or the presence of a slightly stiff neck, 
as well as the rare involvement of the basal cranial nerves ; how- 
ever, both signs occur also in pachymeningitis, if it is located at 
the base of the brain. 

Cekebkal hemokehage frequently is with difficulty differen- 
tiated from pachymeningitis. The absence of the above-described 
symptoms would lead to a consideration of a hemorrhage into the 
brain substance; and the change of symptoms, the choked disc 
and the intercurrent appearance of convulsions to that of pachy- 

In EMBOLISM and thrombosis elevation of temperature is 
rare in the later stages, and phenomena of brain pressure are 

Migraine may also come into question in the basal form of 
pachj^meningitis. Inherited predisposition, as well as a rapid 
course without fever, speaks for migraine. 


While central pains, probably due to lesions in and about the 
basal ganglia, were first suspected by ISTothnagel, it is chiefly to 
the studies of Dejerine and Eoussy that we are indebted for the 
clearing up of the question of pains due to lesions of this region. 

Dejerine and his students have shown that lesions of the 
thalamus, especially of certain of its nuclei, produce a character- 

^ Written by Dr. Smith Ely Jelliffe, New York, U. S. A. 


istic picture, the thalamic syndrome (Jelliffe). in which severe 
and persistent pains form a prominent part. 

These pains usually involve the side of the body on which 
the lesion takes place, and are noted for their severity, their per- 
sistency, and their resistance to analgesics. 

The entire picture of the thalamic syndrome is so character- 
istic that its somewhat — at first sight — anomalous symptoms 
should be given in detail. This is all the more important since 
many patients with the thalamic syndrome are thought to be ma- 
lingerers or hysterical. 

The usual thalamic syndrome begins, as a rule, with a mild 
apoplectiform attack. It may be severe, or it may be so mild as 
to ^escape ordinary observation. After a certain length of time, 
the motor weakness of the early slight or severe hemiplegia disap- 
pears entirely, or to a greater or less extent. The patient has some 
difficulty in managing his hand and leg, and it appears to be dif- 
ferent from the hand of the well side. Then pains are felt on the 
affected side. They may at first have been only uncomfortable 
sensations in the skin of the side; they usually take the form of 
acute shooting pains, and may be in the entire half of the body, or 
may be limited to the face, to the upper extremity, or to the lower 
limbs. They rarely cross the middle line, although in double 
thalamic lesions both sides of the body show painful distributions. 

The nerve trunks are absolutely painless; they are not swol- 
len, and careful search for Valleix's or Trousseau's points is 
unavailing. There is nothing to point to a neuralgic or a neuritic 

These pains stab and jump and throb, and are complained of 
as excruciating. The ordinary analgesics do not touch them ; even 
morphin is unavailing, at times, in checking their severity. 

ITotwithstanding these severe pains, it may be that careful 
sensory examination shows that the patient is unable to distin- 
guish pain at all. This anomalous condition is further compli- 
cated by the fact that a pin prick which cannot be recognized as 
a pin prick, the patient being unable to tell the difference betw'een 
the head and the point of a pin, is nevertheless felt as a disagree- 


able sensation. Here, then, is tlie apparent absurdity of a patient 
who cannot tell pain, yet has a disagreeable sensation when 
pinched, still suffering excruciating pain. ISTot only may the 
patient be unable to tell a pin point from a pin head, but he 
cannot recognize the difference between heat and cold, and burn- 
ing sensations, recognized on the sound side, are translated as dis- 
comfort only on the thalamic side. He also loses superficial sensi- 
bility. The touch of cotton wool is lost. Furthermore, these pa- 
tients have lost their deep sensibility. The position sense is gone, 
and they fail to recognize objects placed in the hand. The rough- 
ness of a lump of sugar may be interpreted as a disagreeable sen- 
sation, but is not recognized as roughness. 

Moreover, these patients show slight motor incoordination 
in the hand or leg; they are ataxic, and more or less choreiform 
or athetoid-like movements are present in the afflicted side. 

In some patients there are residual sigTis of a hemiplegia; 
slight spasticity, perhaps; slight clumsiness, increased radius- 
periosteal reflexes, triceps reflexes ; perhaps lost abdominal reflexes 
on that same side; increased patellar reflex, a clonus and exag- 
gerated Achilles jerks. A Babinski extension of the great toe is 
often absent, but may be present. Chaddoch, Gordon and Oppen- 
heim's signs vary considerably. The motor synergistic phe- 
nomena, described by Babinski, Grasset, and Hoover, are all apt 
to be present. i 

One feature of special moment found in thalamic lesions and 
which has been emphasized by Head and Holmes is an excessive 
response to affective stimuli and the change in behavior in states 
of emotion of the abnormal half of the body. Thus, in many 
cases of pure thalamic lesion, if a pin be lightly dragged across the 
face or trunk, from the sound to the affected side, the patient 
exhibits intense discomfort when it passes the middle line. He 
not only complains that it hurts him more, but the face may be- 
come contorted. JSTotwithstanding this, he is unable to tell 
the difference between the point and the head of the pin. The 
same type of over-response is found to other forms of stimuli. 
Thus deep pressure, which cannot be measured at all, also evokes 


an over-response; the same is true for extremes of heat and cold, 
in spite of the fact that the patient is unable to distinguish be- 
tween them. Visceral sensibility, scraping, roughness, vibration 
and tickling all show this over-response in the affected side. 

l^ot only are painful stimuli over-reacted to, but pleasurable 
stimuli occasion a like over-response. Furthermore, in states of 
emotion, there may be different manifestations on the two sides 
of the body, just as painful and pleasurable stimuli may produce 
a stronger reaction on the affected side. Thus some patients can- 
not hear music without its causing sensations in the affected side, 
or even causing motor unrest, movements of the leg with shaking. 
The choreiform movements, which are notable motor features, 
under the influence of emotional stimuli may be markedly in- 

From this it can readily be seen that the thalamic syndrome 
is a most important clinical picture, and that its more careful 
study is bound to throw considerable light upon the whole ques- 
tion, not only upon the subject of pain-perception, but also upon 
emotional attitudes to all forms of stimuli. In fact, it opens the 
way to the most important of all of the questions taken up in this 
book. Through the study of the thalamus the entire sensory side 
of the human organism will be revealed, and it may readily be 
seen that sensory neurology will be the neurology and possibly 
the psychiatry of the next decade. 

Thus far the study of the thalamus has shown that it contains 
the terminations of all of the secondary sensory paths. In it 
sensory impulses of every kind are regrouped and again redis- 
tributed. This redistribution takes place not only within the 
thalamus itself, giving us thalamo-thalamic paths, but it also goes 
to the cortex in a fairly large series of thalamo-cortical paths. 
The thalamo-thalamic paths seem to pass to important centers, 
constituting what Head "and Holmes have termed the "essential 
organ" of the thalamus which forms the main center for certain 
fundamental elements of sensation. It is a center which is com- 
plementary in function to the sensory cortex, and has distinct 
though related functions. The lateral part of the thalamus con- 


tains the cortico-tlialamic paths through which the cortex influ- 
ences the essential center, controlling and checking its activity. 
Analogous, in a way, is the activity of the motor cortex upon the 
anterior horn nuclei of the medulla and spinal cord. The ex- 
cessive response to affective stimuli, pain as well as others, is 
due to a removal of this cortical control, just as an excessive 
motor reflex reaction recurs when the pyramidal tract does not 
bring down cortical stimuli from the motor area. 

The activity of the thalamic center is of special import in our 
study of pain, for it has been pointed out that in lateral thalamic 
lesions there is an actual overloading of sensation with feeling 

The pains and paresthesise, found in many thalamic cases, 
have been thought to arise from "irritative" lesions, but this is 
probably not so. It would seem that the thalamic center is a true 
center for perception of sensations, including pain, and that the 
cortex has a definite relationship to these, so that it may modify 
the affective response and naturally, thereby, the motor responses. 
The essential thalamic organ is a center for conscious perception 
for certain elements of sensation. It responds to those stimuli 
which are capable of evoking pleasure and discomfort or con- 
sciousness of a change in state. The feeling tone of the body, 
which has often been termed the somatic or visceral tone sensa- 
tion, is a thalamic function. 

What the interrelations between the thalamus and the cortex 
are, so far as sensation is concerned, need not detain us at this 
point. We have chosen to isolate, for the purposes of our treatise, 
that sensation known as pain, therefore a discussion of the whole 
question would be somewhat out of place. Yet, a word should 
be added as to the cortical function in sensation. 

The sensory cortex permits a concentration of attention on 
any part of the body which is stimulated. Such stimuli are 
passing through sensory paths to the thalamus. Many of low 
threshold value pass to the cortex or are automatically taken care 
of by the thalamus. Those of high threshold value pass into 
the essential organ of the thalamus and into consciousness, where 


they bring about a tendency to excessive reactivity, just as the 
anterior horn cells of the cord react excessively if uncontrolled. 
The sensory cortex gives a quick reacting mechanism to dampen 
down the affective . response to thalamic over-activity. 

This leads us to an interesting deduction made by Head and 
Holmes, in the study herein freely made use of, that the aim of 
human evolution is the domination of feeling and instinct by 
discriminative mental activities. This struggle on the highest 
plane of mental life is begun at the lowest afferent level, and the 
issues become more sharply outlined the nearer sensory impulses 
approach the field of consciousness. 

In the accompanying table an attempt is made to simplify the 
diagnosis between a cerebral (sensory) cortex lesion and one of 
the thalamus. The defining factors are obtained principally from 
the work of Head. 







Sensation present, but the response of the 
patient to the same stimulus shows a want of 
uniformity and irregularity of response, so that 
at one time he may respond to a pressure of 
100 gm. and at another 21 gm. may produce 
on the same spot a response. 

Tendency to persistence of sensation so that an 
interrupted stimulus may seem to be con- 
tinuous. Hallucinations of touch, owing to the 
persistency of stimulus sensation, may occur. 

Fatigue quickly results in the part supplied by 
the affected area. That is, the part may re- 
spond to pressure of 30 gm., but will not to 
100 gm. Sensibihty to touch by cotton wool 
is never lost over hair-clad parts. 

No change in the threshold to measurable pain- 
ful or uncomfortable stimuli. No increase or 
decrease of response to painful stimulus. 







May be lost on affected half of body. In all 
cases the objective pain, when present, is defi- 
nite and the threshold of response is con- 

Objective pain lost in half of body. 

Subjective pains are present in the same side of 
the body as the lesion. They are persistent, 
paroxysmal, often are intolerable and yield to 
no therapeutic measures. There is a tendency 
to react excessively to unpleasant stimuli, such 
as the prick of a pin, painful pressure, excessive 
heat or cold ; on the affected side these produce 
more pain than on the normal side. Though 
in some cases the threshold of response may 
be lowered, it requires a less stimulus pressure 
on the affected than on the normal side to pro- 
duce pain. This does not of necessity apply 
to the stimulus produced by a prick, which 
may have no reduced threshold. 









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Diseases within and about the spinal cord produce principally 
two different kinds of pain, namely, back pains and radiating 
pains. The former are more or less continuous, extending 
either along the entire vertebra, or occurring in certain regions. 
The latter occur in the extremities and in the nerve trunk along 
the peripheral portions of the sensory nerves. It would be of 
great value in the diagnosis of spinal cord diseases if the pains 
were at all definitely characteristic. Unfortunately, this is not 
the case. Moreover, there are a number of diseases of the spinal 
cord in which pain is usually absent. Here may be mentioned 
acute poliomyelitis, amyotrophic lateral sclerosis, progressive mus- 
cular atrophies of the nuclear type, multiple sclerosis, and various 
defect anomalies. On the other hand, affections of the cord or of 
the meninges, especially in the initial stages, are apt to result in 
pain. Pains localized in the back are also found in diseases of 
other organs, and there are also in the back radiating pains which 
are not characteristic of diseases of the cord or its membranes. 

It will also be important to consider here those visceral dis- 
eases, chiefly of the musculature of the back, whose pains must be 
differentiated from those originating in the cord or its immediate 
coverings. Not until disease of other organs, which may give 
rise to back and radiating pains, is excluded, can the pain be uti- 
lized for the diagnosis of disease of the spinal cord. One must, 
above all, be able to recognize neck, back and pelvic pains, the 
causes for which are outside of the central nervous system. 

There is an entire class of organs, internal and external, which 



can cause such pains. This class chiefly composes almost all the 
internal organs of the thorax or of the abdominal cavity. For a 
consideration of the back pains due to visceral diseases, see page 

It vi^ill be necessary, in every case of back pain, to exclude 
the entire class of visceral complaints before one sets to vs^ork to 
indicate the pain as originating from the spinal cord or its men- 
inges. Above all, in doubtful cases a systematic examination of 
the internal viscera must be undertaken. If these are found un- 
changed, we must refer the pain to disease of the spinal cord or 
its membranes. If, however, in connection with back pain one 
of the internal organs is found to be diseased, the object of the 
examination will then be to ascertain whether the pains are con- 
nected with these organs or with the central nervous system. 


In certain cord conditions pain is an important factor. We 
will discuss some of these seriatim: 

Luxation and Fracture of the Vertebra. — Luxation and frac- 
ture of the vertebra produce severe radiating pains in the arm, 
trunk or leg, according to the site of the injury. If it lies in the 
cervical vertebra, it may, through compression of the occipital 
nerves, cause pain in their area of distribution. If it lies in the 
thoracic vertebra, it will cause pain by pressure upon the inter- 
costal nerves. The remaining symptoms depend upon the situation 
and remote effect of the lesion. In addition to the sensory signs 
there is paralysis below the site of the injury. The loss of sen- 
sation begins' usually at about the same level, though, as a rulc) 
somewhat lower than the lesion. 

1^0 attempt will be made in this chapter to present a complete 
summary of the clinical pictures of the various forms of spinal 
luxation or fracture. Such must be sought in special works upon 
the subject. We can give only a brief summary of the symptoms, 
laying stress upon the sensory side of the picture : 

1 Written by Dr. Alfred Neuman, Vienna. 


The most classical pictures are produced hj cervical, dorsal, 
lumbosacral and cauda equina lesions. 

The most frequent cause for the first type is direct injury, 
diving, falls, falling of heavy weights. Either dislocation or frac- 
ture may occur. One finds forward displacement of the head, 
there are usually myosis of the pupils, greatest on the side most 
injured, narrowing of the palpebral fissure, retraction of the eye- 
balls — which eye signs are due to involvement of sympathetic cen- 
ters in the first dorsal region of the cord (Dejerine, Klumpke). 
There may be no pain, but there are usually anesthesia and anal- 
gesia below the level of the lesion. The muscles affected indicate 
the level of the lesion in the cord. 

Movement of the head or neck, however, is apt to create sharp 
radiating pains at about the level of the injury. Local pain on 
pressure is present. 

Dorsal injuries cause similar pictures lower down. They are 
usually very severe. 

Lumbosacral and caudal lesions affect the movements of the 
legs and the functions of the bladder, rectum, and sexual organs. 
Lesions here are apt to result in much pain, especially in injury 
to the Cauda equina. In isolated cord lesions, pain is apt to be 
missing, but in caudal involvement, especially later in the disease, 
pain is frequent and very often severe. 

A study of the anesthesias and the muscles involved is neces- 
sary to locate the precise site of the injury. 

Meningeal Apoplexy. — Likewise in spinal cord hemorrhage, 
as the result of a trauma, pains occur. They may be very severe ; 
are localized in the back, and are limited either to a part of the 
same (pelvis, interscapular region, or the neck), or spread over the 
entire vertebral column. Pressure on the vertebra causes a slighter 
increase of pain than does motion ; consequently, the vertebral col- 
umn is held in a stiff position. In like .manner radiating pains 
occur in the upper or lower extremities, according to the location 
of the lesion. The remaining symptoms of the disease present 
themselves in cramps, tremors, and contractures in the arms and 


Hematomyelia.- — Sudden hemorrhage, occurring within the 
spinal cord, in the majoritv of cases causes pain. Some hemato- 
myelias run a painless course. The location of the pain corre- 
sponds to the level of the affected area, and appears either as back, 
shoulder, pelvic or leg pain. Stiffness of the vertebra and pressure 
sensibility of the same are present in involvement of the meninges. 
The patient presents a sudden interruption in the conduction 
paths. The remaining symptoms, produced through the position 
and the spreading out of the area, are disturbances of sensibility, 
bladder and rectal paralysis, atrophies, participation of the arm, 
or half-sided paralyses, etc. 

Caries of the Vertebral Canal. — In this disease pain plays an 
important part. It appears very often as local pain, increased on 
motion, and limited to the diseased vertebra. The result is that 
the patient guards against exercise involving the diseased part, 
and holds it in a stiff position. He also avoids displacement of 
the diseased vertebra. With the local pain, radiating pain ap- 
pears, earlier or later, and has different localizations, according to 
the vertebrae involved. In disease of the highest cervical vertebra 
the pain radiates, through the occipital nerves, to the head (neu- 
ralgia). If the cervical cord enlargement is damaged by bone dis- 
ease, the pain radiates into the arms. In compression of the dorsal 
cord girdle or intercostal pain occurs; and, finally, there is lan- 
cinating pain in the limbs in affections of the lower enlargement 
of the cord. The pressure sensibility of the spinous processes of 
the diseased vertebrae is especially characteristic. It is very pro- 
nounced, and is proportional to the amount of pressure used. 
On the contrary, in neurasthenia and in hysteria (diseases in 
which pressure sensibility of the vertebral column is observed), 
there is greater sensitiveness to a light touch of the skin, on the 
elevation of a fold, than to a strong pressure. In hysteria, pres- 
sure pain is often greater lateral to the spinal process than it is 
over it, and is influenced by suggestion. As characteristic of 
caries, the readiness with which the skin lying over the diseased 
vertebrae responds to pain, to electrical and thermal irritation is 
especially pronounced. The other most important symptoms are 


the acute kyphosis, through collapse of the diseased vertebrae, the 
descending abscess (on the posterior pharyngeal wall, along the 
psoas muscle, or into the inguinal fossa or on the back), and the 
symptoms referred to the spinal cord or the spinal roots. 

Tumors of the Spinal Cord and Vertebrae. — For the diagnosis 
of these conditions, local painfulness of the vertebral column 
and radiating pain must be differentiated. The former corre- 
sponds to the location of the tumor, and is increased, especially 
upon bending forward and on shaking the head. This symptom, 
however, is not always present. It is possible that an 
inequality exists between the strong, spontaneous pain and 
the lighter pressure sensibility. According to Eetren, only a 
diffuse painfulness of the vertebral column can be a symptom of 
cord tumor. 

More frequent and more clearly pronounced are the neuralgic 
pains which arise from pressure on the posterior roots. As a rule, 
they are described as intermittent or remittent, and may be 
present, according to the location of the tumor, in different parts 
of the body. If the tumor is present at the cervical enlargement, 
it causes radiating pains in the areas corresponding to the thoracic 
vertebral column, girdle pains around the thorax, and shooting 
pains in the region of the stomach or bladder. When the tumor is 
located still lower, sciatic pains, on one or both sides, are often 
the first symptoms of the not yet apparent disease. 

In addition to tumors involving the cord itself, as causes of 
pain, one sliould also bear in mind those affections of the vertebrae 
which either themselves encroach upon the cord, or which produce 
such changes in the bones that they make pressure upon, or cause 
involvement of the cord. The most important of the bony dis- 
orders of the vertebrae is tuberculosis. Here there is found 
localized tenderness over the spinal vertebrae, usually sharply lim- 
ited to one or two segments. The general meningeal pain develops 
later, whereas the more severe pressure pain originating from the 
pressure on the roots accompanies the settling of the vertebrae, i. e., 
more or less synchronous with the kyphosis. In caries, also, there 
is no Wassermann, in the fluid the number of cells is rarely high, 


the globulin content nil. (See Caries of the Vertebral Column 
above. ) 

Gummatous masses act like tumors at times, and cannot be dif- 
ferentiated clinically. 

Acute Spinal Meningitis. — If a spinal meningitis is added to 
a cerebral meningitis the symptoms of the spinal trouble are the 
more prominent. Intense pain is frequently observed. There is 
also a local painfulness of the spinal column, especially pro- 
nounced in the lumbar region. The pains are increased by pres- 
sure and shaking (coughing, sneezing), but especially by active 
and passive motion. In the same manner the simultaneously oc- 
curring pains radiating into the arms and legs are increased. For 
this reason the patient holds the vertebral column in a rigid posi- 

Pachymeningitis Spinalis Hypertrophica. — In this disease we 
find pains in the neck, in the occipital region between the shoul- 
ders, and along the spinal column; the point of localization de- 
pending upon the location of the diseased areas. In addition to 
the local symptoms radiating pains in the extremities and in the 
trunk occur. In the cervical variety the neuralgic pains corre- 
spond to the course of the ulnar and median nerves. 

Myelitis. — Pain, which is not the most important symptom in 
this disease, is found especially in the beginning stage, or as a pro- 
drome. In the chronic stages pain is not a constant sign. Back 
pains, varying according to the location of the diseased areas, 
girdle pains, corresponding to the upper boundary of the disturb- 
ances of sensibility, or lancinating pains in the extremity, gener- 
ally not of great intensity, are present. Pressure sensibility, as 
well as percussion sensibility, is almost never found. 

Poliomyelitis of Children. — In the prodromal stages of the 
disease pains are present in addition to fever, convulsions and 
vomiting. These pains are apt to be very diffuse, but are especially 
severe about the neck and occiput, often being more suggestive of 
a cerebrospinal meningitis than a poliomyelitis. Diffuse pains of 
the extremities and marked hyperesthesia, resembling these signs 
in influenza, are extremely frequent, especially in some epi- 


demies. A poliomyelitis may run a course indistinguishable from 
a polyneuritis, save that in the latter bony sensibility is apt to be 
involved. It is rarely implicated in poliomyelitis. Associated 
with poliomyelitis is paralysis, which generally occurs suddenly 
in the course of the night, in from two to seven days, and affects 
either one or more extremities, generally one or both limbs. The 
paralysis is flaccid, and the skin and tendon reflexes are absent. 
After a short time atrophy of the muscle and reaction of degen- 
eration are demonstrable. Then the affected limbs feel cold and 
are livid in color. Atrophy and secondary contractures ensue in 
many cases. 

Syphilis of the mening-es and of the cord causes pains in dif- 
ferent parts of the vertebral column, which are increased through 
movement and pressure, are of gTeat severity, with nightly exacer- 
bations, and are combined with radiating pains in the extremities 
and the trunk (girdle pain). Through compression of the ante- 
rior roots there also occur atrophic paralyses of the extremities 
and of the abdominal muscles. The participation of the spinal 
cord can be seen through an interruption (very incomplete) 
of the conduction. Spastic paralysis of one or both extremities 
is also of frequent occurrence. Babinski's and Oppenheim's signs 
are then present, as well as disturbances of sensibility in the rec- 
tum and bladder. The frequent change of the disease picture is 
characteristic. Paralysis maybe present one day and then disap- 
pear, and it may frequently be observed that paralysis and per- 
fect motion follow one another in the same region. 

Multiple Sclerosis. — The pains are similar to those found in 
tabes, but are much less frequent. Some pain is obsen^ed along 
the spinal column. The remaining symptoms are familiar, 
namely, spastic paretic symptoms in the extremities, intention 
tremor, scanning speech, nystagmus, passing disturbances of sight, 
with paleness of the papilla, headache, dizziness, and mental signs. 
In the later stages, marked by intense contractures, pain is often 
very intense. It is due to the contractures and may also appear 
early in the disease as short stabs, occurring at the time of a con- 
tracture cramp of the extremities, principally the lower. 


Syringomyelia. — The pains which are most often observed in 
this disease are similar in character to the lancinating pains of 
tabes dorsalis. They are often very severe, and radiate into the 
limbs (sometimes into all four) and around the trunk. The other 
symptoms concern the development of atrophic paralysis, princi- 
pally, at first, in the upper extremities, beginning in the small 
muscles of the hand. The sensory syndrome consists in a retention 
of epicritic touch sensibility, but a loss of pain and temperature 
sensibility. Vasomotor and trophic disturbances are frequent 
from involvement of protopathic conduction fibers. 

Tabes Dorsalis. — The pains in tabes dorsalis are localized 
sometimes on the surface of the body, sometimes in the hollow vis- 
ceral organs. The former appear as lancinating pains in the ex- 
tremities, or as girdle pains around the trunk. These pains form 
one of the first symptoms, and often appear many years previous 
to other symptoms of the disease. They come on abruptly, while 
the patient is in the best of health, and soon reach a great in- 
tensity. They are situated, as a rule, less frequently in the upper 
than in the lower extremities. In the former case, they are 
usually not so severe. In the legs they may reach their greatest 
intensity. The pain suffered by different patients, however, varies 
in intensity. It is seldom felt in the skin, but, instead, usually 
deep in the muscles or in the bones. The attack itself may last 
for a few seconds at first, then, later in the disease, a few minutes, 
then, in the final stages, may persist for hours. The incidence of 
the attacks seems to at least partly depend upon outside factors, 
as weather, worry, wine, and women. The girdle sensations indi- 
cate only different localizations of the lesion. They appear as 
pressure, tightness on the breast, as though the patient were 
bound by an iron band, or as pressure sensation of the stomach 
or bladder. Pains in the maxilla, teeth, or ear may occur in 
tabes, in fact, in the distribution area of any sensory nerve. The 
pains which arise in tabes in the internal organs (stomach, blad- 
der, intestines) occur paroxysmally, and are often of extreme 
severity, when they are termed tabetic crises. Such crises are not 
infrequently very early. The best known are the stomach crises. 


A patient in perfect health suddenly has excruciating pains in the 
stomach, usually accompanied by uncontrollable vomiting. Ra- 
diations into the shoulders occur. Some patients scream, sigh, and 
toss in bed, while others remain perfectly quiet. This condition 
lasts a few hours, or days, rarely longer. Then the picture 
changes. The pains and vomiting disappear, and the patient is 
able to cat everything without distress, the same as though he were 
in perfect health. These intervals of freedom last for different 
periods, sometimes months or years. Then other crises occur. In 
the intestines the crises arise as colicky pains associated with 
diarrhea; kidney crises, with pains similar to those of renal colic, 
also occur; bladder crises, ureter crises, and clitoris crises, corre- 
sponding to pains in these organs ; eye crises, sudden pains arising 
in the eyes, joined with redness, lancination and contraction of the 
lids ; laryngeal crises, sneezing crises, etc., also occur. 

The associated symptoms are so numerous that only the 
most important can be mentioned, namely : 

(1) Disturbances of sensibility, and, in addition to the pain, 
paresthesias, especially in the extremities, paralysis of sensibility 
of the skin, of the muscles, and of the joints. 

(2) Disturbances of the reflexes with absence of the patellar 
reflex or of the tendon achilles reflex, the tendon reflexes of the 
upper extremities, and of the pupil reflexes (Argyll-Robertson). 

(3) Ataxia of the extremities, shown by the finger-nose test, 
finger-finger test, knee-heel test and by Romberg's test. 

(4) Bladder and rectum disturbances, especially inconti- 

(5) Trophic disturbances leading to spontaneous fracture, 
atrophies of the joints, arthropathies, falling out of the teeth, and 
perforating ulcer. 

(6) Eye symptoms, which are often temporary, ptosis, oph- 
thalmoplegies, optic nerve atrophy. 

Neurasthenia. — Pain in the back of the head is a frequent 
complaint of many neurasthenics. It is localized to a circum- 
scribed part of the vertebral column, or spreads out over the 
entire circumference. One finds pressure sensibility in a lesser 


or greater part of the spinal column corresponding to the loca- 
tion of these pains. It is characteristic that strong pressure is 
often felt to be less painful than light pressure. The pains are not 
as severe as they are described, as may be seen by the ease with 
which the patient's attention is distracted from the pain. Radiat- 
ing pains in the trunk and in the extremities are also frequently 
described. In regard to the other symptoms of neurasthenia, they 
are so numerous that the mere enumeration would be too exten- 
sive. They may be found in text-books of neurology. 

Hysteria. - — The pains of hysteria are similar to those of neu- 
rasthenia. Pressure sensibility in the back, over one or more 
spinous processes, as well as the other peculiarities of neuras- 
thenia, are present in hysterical back pain. 

Traumatic Neuroses. — If the trauma strikes the spinal col- 
umn directly or indirectly, pain which hinders the patient from 
making active movements may occur in the involved area. 

General Summary. — It is even far more difficult to draw diag- 
nostic conclusions from the character of spinal pains than it was 
from headache pains. They have little of characteristic pecu- 
liarities. The nightly exacerbation of luetic pains, as a single 
exception, is almost the only one pointing directly to an etiological 
factor. In spinal-cord affections, local pain, local pressure sensi- 
bility, and radiating pains are singly or in combination diagnostic 
criteria of value. They may occur separately, but are usually 
found together. Diagnostic conclusions can rarely be drawn from 
the severity of the pains alone. The highest degToe of radiating 
pain is found in caries and tumors pressing upon the spinal cord, 
as well as in meningeal apoplexy, meningitis, and meningomyelitis. 
The severity of the pain depends more upon the extent and the 
degree of the process than on its nature, so that the intensity of 
the pain, in the diseases described, may be greater or less, accord- 
ing to the stage of the disease. It should be observed that pains in 
the back, along the entire spinal cord or a greater part of it, in 
neurasthenia are almost always of a minimum intensity, though 
they are described by the patient as being very severe. Observa- 
tion of the patients, however, shows that they are bearable pains. 


In most cases of localized spinal affections the pains are not spread 
out over the entire vertebral column, but affect only circumscribed 
parts of one or a few vertebrae. A pain limited to a circumscribed 
area frequently is valuable for a diagnosis; not so much for the 
recognition of the trouble itself, as for the determination of its 
location. The sudden darting pains of tabes are almost pathogno- 
monic, as are also the crises pains. 




Muscles are subject to pain and seem especially to be affected 
in the acute infectious diseases, or in those conditions which go by 
the rather loose term "colds." The majority of these diseases are 
due to bacterial invasion, with the production of toxins, and it is 
these toxins which seem to have a selective action on the sensory 
nerve receptors distributed in the muscles. 

For a long time it was not definitely known that sensory nerve 
receptors existed in muscular tissue, Sherrington, however, dem- 
onstrated the existence of such organs, and Head, by his thorough 
technique, showed that the origin of deep sensibility was undoubt- 
edly muscular and tendinous. As yet, though we know that they 
exist, the sensory end organs in the muscle tissue have not been 
definitely isolated. In some cases these end organs, or sensory 
nerve filaments, become hypersensitive. The hypersensitiveness 
may be confined to the muscles alone, the overlying skin being 
uninvolved or both the skin and muscle may be involved. Tender- 
ness of the muscles may be elicited by grasping them between the 
fingers, or by making pressure on them. At the same time pinch- 
ing the skin may give no reaction, for the reason that the deep sen- 
sory system may alone be affected, the skin systems not being im- 

In a consideration of the pain-producing diseases of the 
muscles it is better to divide them into the voluntary and invol- 
untary, for what would produce a painful reaction in the volun- 
tary often has absolutely no effect in involuntary muscle; for 


instance, inflammation in- voluntary muscle gives rise to very 
severe pain, while in involuntary muscle it may not produce the 
least sign of its presence. In either case the stimuli which react 
to cause pain are the same, but those in the voluntary muscles 
act upon sensory termini which are accustomed to respond to 
inflammatory irritative stimuli by pain, while in the involuntary 
muscle the sensory termini have had no such training, and react 
only in response to an entirely different set of stimuli. In the 
voluntary muscles the pain syndrome may be produced in a 
flaccid muscle by the action of bacterial toxins on a sensory nerve 
terminal, while in the intestine it is necessary that to the bacterial 
invasion a contraction of the muscle fibers also be added before 
pain is produced. 

A condition in which all voluntary movements have been asso- 
ciated with great pain has been described by McCarthy (Osier's 
System, VI, 569). He terms it Akinesia Algera. 


The diseases of voluntary muscle causing j)ain are myositis, 
acute polymyositis, myositis fibrosa, myositis ossificans and my- 

Myositis. — When inflammation of a muscle (myositis) occurs, 
the pain is found in definite areas corresponding to the muscular 
distribution. The pain may be so severe, and every movement 
so provocative of pain, that the patient is unable to move, and 
lies in bed like one paralyzed. Different groups of muscles may 
become involved successively. The involved muscles, as a rule, 
are greatly swollen. The pains are described as drawing, tear- 
ing, or boring (Steiner). In other cases, no definite inflamma- 
tory state can be defined, but severe pain is pro4uced on move- 
ment of a certain gToiip of muscles. This is very common in 
women of feeble muscular development, and is "felt at the attach- 
ments of the abdominal muscles to the ribs, or along the attach- 
ments of the erectors of the spine. These, in reality, are stretching 
pains, and are due to an abnormal pull upon the tendinous struc- 


tures from deficient muscular support" (Thompson, 36). In 
these cases the skin may be very hypersensitive over the insertion 
of the involved muscles (Moullin, 226). In other cases pain is 
present in the skin over the entire extent of the involved muscle. 
This would seem to lend credence to that part of Hilton's law 
which states that skin over involved muscles is tender in disorders 
of these muscles, because both have the same nerve supply. This 
cannot always be true, however, because, as already explained, 
while the muscle and overlying skin might originally have been 
supplied by the same nerve or nerves, yet, owing to development 
and consequent change in the relative position of both the skin and 
its underlying muscle, it frequently happens that the skin is dis- 
placed to a considerable distance away from its original position 
over its nerve-related muscle. 

Of the acute forms of myositis the suppurative variety soon 
lends itself to ready diagnosis, not from the pain, which at first 
resembles that of a generalized neuralgia, or is of a rheumatic 
type, but from the rapid localization in the involved muscle of 
the characteristic tender indurative swellings, hard and board-like 
in character. Muscular contractures are the rule. Softening and 
fluctuation soon determine the true nature of the pain. Suppura- 
tive myositis may be multiple or isolated. 

Acute Polymyositis. — The form of myositis which has just 
been discussed is largely a local affair affecting one muscle or a 
small group of closely related muscles. In persons of early or 
middle life there exists, however, a form of acute generalized in- 
flammation of the muscles — a polymyositis — in which pain is a 
prominent symptom. 

This disorder, frequently a complication of other infectious 
disease, also of generalized toxemic states, usually begins with 
acute constitutional symptoms, malaise, headache, nausea, vomit- 
ing. Dragging pains then occur, with frequent cramps in the 
entire musculature. At first the sore spots are fairly well local- 
ized, tender to pressure and to passive motion. Then a period of 
inflammatory edema makes its presence manifest by swelling and 
hardness of the parts. These swellings may at times give the 


muscles a somewhat grotesque appearance. The skin is tense, 
often reddened, and may show exanthemata, erythema, urticaria, 
or vesicles. The electrical excitability diminishes, and atrophy 
takes place after the hypertrophy has disappeared. The epicritic 
sensibility is unimpaired. Careful search should always be made 
of the blood picture, as certain forms of polymyositis are associated 
with eosinophilia, which not infrequently has as its underlying 
cause a localized or generalized trichinosis. Other parasites are 

Myositis Haemorrhagica. — In myositis hsemorrhagica pain is 
the first symptom. It is usually sharply circumscribed to a spot 
in the muscle where a small nodular, palpable tumor usually de- 
velops. Edema soon sets in and hemorrhagic areas are observed, 
which soon show the familiar yellow-green discoloration. 

Myositis Fibrosa. — Myositis fibrosa often shows itself in sharp 
pains in the muscles, the lower extremities usually being first im- 
plicated. The disorder advances slowly, going from one muscle 
to another, and the patient, after several months or years, is un- 
able to move about because of the pain and rigidity. Contractures 
occur, but sensory disturbances are rare. Palpation is usually 
painless in this particular variety, and much weight is laid by 
Lorenz upon this feature in diagnosis. The muscles get harder, 
but the spontaneous pains become less pronounced. 

Myositis Ossificans. — In myositis ossificans the pain often 
masks the case as one of "rheumatism." In some pain is lacking 
in the early stages. The usual signs of myositis are present in 
most cases, with radiating pains. Following an attack, the pain 
subsides, but the muscles remain hard and indurated. Other 
attacks come and go, the indurations becoming harder and harder, 
until bony masses are evident. The disorder is found most fre- 
quently in the muscles of the back and neck, the face and upper 
extremities less frequently, while the muscles of the lower ex- 
tremities are rarely involved. The gradual rigidities that develop 
with the deformities are very striking. 

Myalgia. — Torticollis and lumbago are the most classical of 
the myalgias, although any muscle of the body may show this 


peculiar disturbance. Myalgias are very frequent, yet, notwith- 
standing, the cause is very obscure. Exposure to cold and trau- 
matism are among the most frequent etiological factors. 

The pain is usually sharp, especially when the parts are moved 
and the muscles forced to functionate, actively or passively. In 
torticollis, in which the sternocleidomastoid is affected, the pa- 
tient holds the head to one side, and the pain is very 
severe and is usually imilateral. In lumbago the pain is 
in the back. The onset is usually sudden, often following a 
muscular strain ; every movement becomes extremely painful, and 
the position adopted by the patient is very characteristic. He 
walks with a stiif, short tread. Lumbago may be confused with 
spinal arthritis, with sacroiliac disease, with malignant spinal 
growths, or even tuberculosis of the spine. Other muscles (pleu- 
rodynia, scapulodynia, dorsodynia) afford other special pains and 
special postures. 

The muscles are often somewhat painful to pressure, and occa- 
sionally they are indurated ; at times the induration is soft, again 
it is hard. Counterirritation and massage often relieve the con- 
dition very rapidly. 


Colics. — Thus far only voluntary muscles have been consid- 
ered. Involuntary muscles, also, are the site of pain sensation, 
especially those which are present in the hollow viscera. Here 
the pain is associated with contractures or spasms. These con- 
tractions or spasms, when they occur in the intestinal, genito- 
urinary, or biliary tracts, are called colic. The pain in colic is. 
constant, as a rule, but may have periods of greater or less in- 
tensity. Of all colics, perhaps, that of the common gall-duct is the 
most severe. 

Colicky pains show variations. In some cases there is a sudden 
increase of pain, which persists for a longer or shorter period and 
suddenly disappears. In another type the colicky pain comes on 
suddenly, then remits, and in a few hours returns and becomes 


very severe. This may be repeated many times. In a third variety 
the pains at first are light, but become of gradually increasing 
intensity, with an incomplete remission between the paroxysms 
until a paroxysm of maximum intensity occurs, when there is a 
gradual remission and return to the normal. 

Several factors enter into the causation of colicky pain. 

(1) The pains may be due to the overdistention of a portion 
of the canal lying between a distal, non-moving, contracted part of 
the canal, and a movable, contracting part, the movable part gradu- 
ally approaching the stationary part until the contents in the in- 
tervening canal are put under great pressure and consequent dila- 
tation and overdistention of the canal take place. This over- 
distention causes a stretching and pressure on the nerve terminal 
filaments in the wall, and pain results. JsTormally this overdisten- 
tion does not occur, for it is a rule, in all hollow muscular viscera, 
that contraction of one portion is followed by relaxation of the 
next adjacent portion. It is only when this law, called by Meltzer 
(105b)' the "law of contrary innervation," is at fault that colic 

(2) Pressure may be made upon the terminal nerve fila- 
ments by the contracting muscles. 

(3) Traction and pull is made on the mesentery by the in- 
equality in position of the contracted and noncontracted seg- 

(4) During contraction of the bowel it tends to straighten 
out and this causes a pulling and stretching of the mesentery. 
In fact, it seems that this is the most reasonable hypothesis. This 
is contrary to the idea of Hertz that tension is the only true 
cause of hollow visceral pain. In intestinal colic, relief almost at 
once follows the onward passage of the feces. The pain of intes- 
tinal colic is not felt so much in the viscera, but is referred to 
the anterior abdominal body wall, and follows the law of seg- 
mental distribution (Head). Hertz, on the contrary, claims that 
the referred pain is rarely present alone to the exclusion of a true 
visceral pain, but that the visceral pain is often present to the ex- 
clusion of the referred pain. 



Adiposis Dolorosa. — In this condition, first described by Der- 
cum in 1888, pain is a prominent feature. It is a pain, boTvever, 
that is more the result of pressure than spontaneous, although there 
usually are burning, lancinating sensations present in the fatty 
masses, which form the characteristic features of the disease. 

Diffuse collections of fat, scattered over the body, are found 
in several conditions. Adiposity shows itself under several forms ; 
chief of these are the adiposis tuberosa of Anders, adiposis cere- 
bralis of Frohlich, formerly prophyseal or epiphyseal disease 
(Marburg, Jelliife), symmetrical adenolipomatosis, multiple lipo- 
matosis and adiposis dolorosa. These are probably closely related 
conditions, and pathologically some relationship to the ductless 
glands, particularly the hypophysis, is probable. 

Adiposis dolorosa varies from the others by reason of the pain 
and tenderness of the fatty masses. This pain is probably the re- 
sult of an associated neuritis, since neuritic lesions have been found 
in a number of cases. Furthermore, tender nerve trunks, trophic 
changes, and sensory symptoms go to round out the picture of a 
neuritic involvement. 

The fatty areas, as they develop on a basis of a general adipos- 
ity, are usually edematous and tender. Pressure induces an ex- 
quisite painfulness, and leaves behind it burning, lancinating 
sensations. The areas have a tendency to disappear, leaving in- 
durated spots ; then recurrences take place, and nodular tumors 
develop. These nodules, which are very sensitive — even to the 
slightest touch — often giving rise to exquisite pain, are found 
principally over the trunk and extremities. The face, hands and 
feet are free. Cases are also met with, with no nodules. Here 
there are large indurative areas, sensitive to touch and palpation. 
There is a tendency for these areas to become less sensitive, but 
nodules which remain in the fat retain an exquisite tenderness, 
and are the centers for neuralgic-like radiating pains. 

Pain is present usually at all times. It may be an initial 
symptom, coming on before there are any fatty nodules. It may 


be dull, lancinating, or burning; rarely is sharply localized to 
any nerves, but is usually associated with tender nerve trunks. 

Asthenia, querulous irritability, mental apathy, and depres- 
sion are frequent associated conditions, while general neuritic 
signs, such as anesthesise, hyperesthesise, vasomotor disturbances, 
hypersecretion, cyanosis, demographia, ulcers, ecchymoses, all con- 
tribute to the general evidence to show some implication of the 
protopathic system. 

In all cases of adiposis dolorosa examination should be made 
for hypophyseal symptoms. In many cases of this disease an 
adenoma of the posterior lobe of the hypophysis has been found 




When pain occurs in a limb over a region where bone involve- 
ment is a possibility, it is necessary to consider lesions of struc- 
tures overlying the bone, as well as those of the bone itself. It 
is only when pathological lesions in the overlying structures have 
been eliminated that the bone should be considered as at fault. 
When a patient complains of pain in bony structures it is neces- 
sary first to obtain a history of the pain, its type, manner of onset 
and character, and then to proceed to a physical examination of 
the affected region. Of the physical methods of examination 
made use of in the elucidation of bone symptoms, palpation is 
productive of the best results. If palpation over a limb or a part 
where bone is a prominent structural component discloses only 
superficial pain, the bone can be disregarded as the chief cause 
of the pain; yet it should always be borne in mind that a lesion, 
which at first may have commenced in the bone, may progTess so 
that adjacent tissues are involved and secondary lesions ensue. 
These may be far worse, and produce symptoms of much greater 
severity than the original disorder, so that often in the medical 
survey the secondary lesion intrudes itself to such a degree that 
the original primary condition is overlooked. As a rule, however, 
if tenderness and pain are both superficial, and there is no his- 
tory of a previous deeper pain, the bone may be disregarded and 
the superficial tissues considered as being at fault (bone lesions 
are tender and painful on deep pressure). 



In our examination as to the cause of the bone pain, inquiry 
must be made as to its type, i.e., whether it is continuous or inter- 

Continuous pains are due to persistent acting causes, such as 
new growths, inflammation or aneurysm. !New bony growth gen- 
erally produces a dull, aching pain, which, as a rule, is fairly well 
localized to the area affected. Inflammation of bone produces 
a continuous pain, which is interrupted at times by paroxysms 
of greater intensity. Pressure on a bone by a growing tumor or 
an aneurysm (with gradual erosion of the bone) causes a dull, 
aching pain of great severity. In this condition there is a sharply 
defined area, exquisitely tender to the touch, corresponding to 
the site of the bone involvement. Other signs of tumor or 
aneurysm are also present. 

Intermittent pain in bony lesions is divided into two classes ; 
in the first, the pain occurs spontaneously, without any excess of 
local irritation, and generally indicates a more severe process than 
in the cases where pain is felt only on pressure. When pain is 
only felt on pressure (if the bone is only slightly involved) it 
disappears from the part as soon as the pressure is removed; but 
in more severe cases it may persist for some time after the re- 
moval of the pressure. 

In some cases there are recurring attacks of very violent 
pain, with great tenderness at the point where the pain is felt. 
When this pain and tenderness are accompanied by local swell- 
ing, fever, and a rapid pulse, osteomyelitis should be considered. 
Pains of this type, spontaneously occurring at intervals without 
any apparent existing causes, are called spontaneous intermittent 
pains. The other forms which can be produced by pressure are 
called pressure intermittent pains. These occur generally in 
association with an inflammation and are either mild or severe, 
depending upon the amount of pressure which is necessary to be 
exerted on the part to produce pain. Among the pressure inter- 
mittent pains are those due to osteomalacia and osteomyelitis. 


Diurnal variation of the pains is of great value in the diag- 
nosis of bone lesions. Pains due to certain diseases seem to appear 
at regular and definite periods of the day. Syphilitic and tubercu- 
lous bone pains are generally worse at night. A point of impor- 
tance is that luetic pains are always relieved by mercury and the 
iodides, and tuberculous lesions give tuberculin reactions and the 
serological test (Wassermann's) is present in lues. Nocturnal 
ostalgia is very common in typhoid fever, especially in patients in 
whom the bone marrow is involved, so that when a limb pain is 
present in those convalescing from typhoid fever the bone should 
always be examined.^ 


According to its severity bone pain may be classified as sharp, 
piercing, dull, or aching. When the pain is sharp, it is generally 
of. sudden onset, and comes without warning. If it is very severe, 
and is sharply localized, osteomyelitis is most likely to be present. 
Piercing pain is not common in bone disease, and, when present, 
neuralgia should be sought. 

Dull and aching pain is characteristic of syphilitic lesions. 
When present an examination for past or present syphilis should 
be made. It is also present in periostitis, in which at the point 
of periosteal thickening a dull pain, with at times more or less 
acute exacerbation, is felt. When the periosteum is diseased, a 
well-marked, localized thickening will be found on X-ray exami- 


With reference to extent, bone pains may be classified either as 

localized or diffuse. Localized bone pains are due to periosteal 

lesions, traumatism, new growths, and inflammation. 

1 It seems that the medulla of bone, perhaps the endosteum, is much more 
sensitive than the periosteum, for recently in our (Dr. Sehultze and myself) 
work on bones we have found that the cutting of the periosteum or the tre- 
phining of the cortex was not especially noticed by the morphinized dog, but 
as soon as the drill penetrated the medullary cavity he became restless and 
whined very much. Later in the experiment, when it became necessary to in- 
troduce a sound or curette into the narrow cavity, he again showed signs of 
apparent pain. 


Periosteal Lesions. — The periosteal lesions causing pain are, 
as a rule, inflammatory. If the inflammatory changes occur at the 
point of the insertions of muscles or tendons, any activity of the 
muscles or movement of the tendons will cause pain, and in some 
cases this may be confused with pain produced in the bone itself. 
In periosteal inflammation tenderness is sharply limited, which, as 
a rule, is not the case in lesions of the bone itself. The tender- 
ness is nicely defined by running the finger down to and over the 
inflamed area. In lesions of superficial bones like the tibia 
marked pain is evinced as soon as the finger crosses the border of 
the inflamed area. 

Should swelling of the periosteum occur without pain, it may 
be due t(f a new growth which causes pain only when the sub- 
periosteal distention becomes so great that pressure is made upon 
the sensory nerve filaments terminating in the periosteum. 

In children the so-called gTOwing-out pains are often the result 
of slight septic processes in the periosteum. They often appear 
after acute infection, tonsillitis, etc. 

Traumatism. — Here the pain is of sudden onset and immedi- 
ately follows the injury. If the part is too tender to palpate, an 
anesthetic may be used, so that a proper diagnosis of the condi- 
tion can be made. If possible a skiagraph of the part should be 
taken. This will save considerable manipulation of the injured 
region, and will lessen the necessary pain to the patient. Tl the 
X-ray is not available the presence or absence of fracture should 
be determined from crepitus and false motion. If a fracture is 
found its probable direction and extent should also be determined. 
Following an injury, if localized tenderness is present and the 
bone has not been broken, bruises and contusions must be consid- 
ered. These may also occur in the periosteum, in which case the 
tenderness is present as a rule only on deep pressure. It is neces- 
sary to consider fractures, bruises and contusions separately. In 
some severe injuries all these may be included in one lesion, which 
is called a crush. 

Fracture. ^ — In fractures pain may be entirely or almost en- 
tirely absent, particularly when the fracture is an impacted one. 


This occurs only in the absence of laceration of the adjacent parts. 
Pain may also be absent when the fractured ends of the bone are 
separated by a considerable interval. In fractures pain is elicited 
by two methods : First, by passive motions, to produce which the 
limb is grasped so that one hand is above the line of fracture and 
the other below it, and to and fro movement is made so that there 
is motion between the fragments ; when a fracture is present, pain 
is felt, sharply localized at the point of fracture. Second, if pres- 
sure be now made over the point of greatest pain, a well-marked 
area of tenderness, corresponding rather closely to the line of 
fracture, is found. In some fractures the line of the fracture may 
be outlined by the sharply defined area of tenderness immediately 
above it. This line of tenderness is very useful in diagnosing a 
greenstick fracture in which crepitation and false movement are 
absent. In certain cases of impacted fractures, for instance, those 
of the femur, great care should be exercised in the manipulations, 
so as not to break up the impaction ; otherwise, especially in old 
people, a condition in which union does not occur will result. A 
point of considerable importance to remember in the diagnosis of 
fracture is that tenderness persists for a considerably longer period 
in a fracture than in a simple contusion. If the pelvis should be 
injured and a fracture suspected the crests of the ilium should be 
forcibly pressed toward the middle line. When a fracture is pres- 
ent there is a well-marked and sharply defined pain at the point 
of fracture. 

Contusions. — Bruises and contusions generally are the result 
of direct violence, and are localized in extent. The periosteum is 
markedly elevated and under it a blood clot, felt as a soft, fluctu- 
ating mass, may h.e present. If in a lesion of this kind in which, 
the swelling is beneath the periosteum the pain increases, instead 
of decreases, it is likely that infection has occurred, particularly 
if the swelling continues to increase in size and becomes softer. 

New Growths. — As a rule, new growths of bone are not pain- 
ful ( ?) until the periosteum is involved, or until pressure is made 
upon adjacent tissues, when they give rise both to local and re- 
ferred pain. Resembling new growths, tuberculous disease of the 


bone may be present for some time without producing pain, but, 
as a rule, it soon gives rise to a dull aching, which, if the adja- 
cent joint is involved, is interrupted by sharp paroxysms. 

Septic Involvement. — Septic involvement of the osseous sys- 
tem is frequently encountered during pneumonia and malaria. It 
also is common during the course and convalescence of typhoid 
fever, the bones must frequently affected being the ribs, tibia, 
femur and clavicle. This septic involvement, and, in fact, all in- 
flammatory changes, can occur only in the bone marrow and 
the cancellous tissue, because the hardness and density of the cor- 
tex inhibit inflammatory reactions. To these inflammatory 
processes the name osteomyelitis has been given. The pain of 
acute osteomyelitis is of the greatest intensity. According to 
ISTichols, it is the most intense of any pain with which we are 
familiar. Osteomyelitis of the long bones often commences 
with a sharp, sudden pain in the vicinity of the epiphyseal line. 
A sign of great significance in the diagnosis of osteomyelitis is that 
continued, gentle pressure on the shaft of the bone, at a distance 
from the area of greatest pain, will at first produce no pain, and 
then, very suddenly, there will occur a sudden short exacerbation 
of great severity. Acute osteomyelitis generally gives acute symp- 
toms, but it must not be forgotten that, either following such an 
acute attack or arising de novo, a chronic osteomyelitis may be 
present and give rise only to a dull aching, in some cases, gnawing 
pain in the affected area. 

Changes in the structure of a bone not only may be the result 
of germ infection, but may also be produced by diseases of the 
hemopoitic system, such as leukemia and pseudoleukemia. In 
such conditions pain is frequently present in the lower part. of the 
sternum. It is produced by pressure against the bone. Such pres- 
sure may occur while leaning against the edge of a table, in writ- 
ing, on resting on the window-sill, or on bending over the washtub. 
Pain of this type is often the first manifestation of leukemia or of 
a pseudoleukemia. 

Schmidt has made the interesting observation that in leukemia 
and pseudoleukemia the sternal pains are controlled by arsenic, 


and that during the period of greatest activity of arsenic the pains 
are less troublesome. He has also found that the bone pains in- 
crease and decrease with the increase and decrease in the number 
of the leukocytes. 


The diseases causing generalized bone involvement and giving 
rise to pain are : Osteomalacia, diseases of the hemopoitic system, 
and new or abnormal growths. 

Osteomalacia occurs most frequently in association with preg- 
nancy. The pain is usually found in the lumbar region and in 
the lower extremities. It is produced by any action which causes 
motion in the affected bones. Such actions as walking, stooping, 
rising from a sitting to a standing posture, laughing, sneezing and 
coughing produce great distress. Schmidt well describes it thus: 
"On getting out of bed, the patient subject to osteomalacia care- 
fully lifts out each leg in turn, holding it by the thigh." Deep 
respiration often gives rise to pain in the ribs. Descent of the 
stairs is sometimes more uncomfortable than the ascent, because 
of the jarring of the body that it occasions. While moving about 
is exceedingly arduous, remaining in the same position for any 
length of time, either sitting or lying, results in an increase of the 
pain. The patients are thus obliged to change their positions 
constantly, and their sleep is very broken. Abduction as well as 
rapid dorsal flexion of the hip causes paroxysms of pain located at 
the ankle joint. In the latter case the pain often runs the entire 
length of the lower extremity, radiates to the pelvis, and is some- 
times accompanied by dorsal clonus. Lateral compression of the 
thorax, or of the pelvis at the level of the trochanters or iliac crest, 
promptly causes pain. The wearing of a corset and tight lacing 
sometimes appear to relieve the subjective symptoms, evidently 
through the support given to the spinal column. Osteomalacia 
should be carefully diagnosed from spondylitis of the dorso-lumbar 
region, in which, during the early stages, the character of the 
pain may be somewhat similar. 


Diseases of the hemopoitic system, as leukemia and pseudoleu- 
kemia, also cause aching pains in the long bones. (See above.) 

ISFew growths of bone are sarcoma, carcinoma, myeloma, 
lymphadenoma ossium, and chloroma. 

Sarcoma and Carcinoma.- — Should pains be associated with a 
tumor mass and at the same time with cachexia, search should be 
made for malignant bone disease, and one of the best methods of 
diagnosis is the X-ray. In suspected cases the adjacent lymph 
glands should also be examined for swelling and the skin should 
be inspected for the red lines caused by affected lymph radicles 
(running from the site of the disease to the nearest lymph gland). 

Myeloma, lymphadenoma ossium, and chloroma cause diffuse 
pain and are associated with the symptoms of internal lesions. 
Malignant metastatic growths also are frequently found in bone, 
and cause pain which at first may be delimited and localized ; but 
finally, with the involvement of the entire bone, the pain also 
becomes diffuse. 

Abnormal growths of bone causing pain are osteitis deformans, 
and leontiasis ossea. 

Osteitis Deformans. — In case of long-continued pain in the 
legs, with occasionally tender points over the bone, osteitis de- 
formans, or Paget's disease, may be found. Its presence is further 
indicated by the constantly increasing size of the head. 

Leontiasis ossea is also a rather frequent cause of bone pain. 

Spurs growing out from bone are also a cause of pain. When 
they grow out of the os calcis, they are often the cause of the 
so-called painful heel. 


Bone pain should be differentiated from that due to bursitis, in 
which a painful swelling is located over the site of a bursa. Pain 
is present only in acute bursitis. In the chronic form it is absent 
unless an acute process is engrafted upon the chronic one. Of 
somewhat frequent occurrence are the neurotic ostalgias, the so- 
called functional pains. In some cases the diagnosis. from the or- 


ganic form of pain is very difficult, but on examining under 
anesthesia in those suffering from neurotic ostalgia no loss of func- 
tion is apparent and no abnormal change in the tissues can be felt. 
An X-raj examination also shows no pathological change ; at the 
same time there is no definable change in the relationship of the 
bone to the surrounding parts. 

Hysteria may be differentiated by associated areas of anes- 
thesia and hyperesthesia, as well as by the eye symptoms. IsTerve 
lesions, such as neuralgia and neuritis, are distinguished by their 
characteristic symptoms. Referred nerve pain is sometimes pres- 
ent in a bone, but this is not so difficult to diagnose. Local symp- 
toms of disease are absent, while diseased areas are present at 
a distance. Pains may also be referred from a bone to a distance ; 
such pains referred are often found in diseases of the vertebrae, 
however, in which case pressure over the spinal column is very 


Classification.' — Joint pains are of two classes: organic, in 
which the pains are due to structural changes, and non-organic, 
in which no apparent structural change can be found. In the 
former the pain appears when the affected organ begins to func- 
tionate. Under the latter class are included the hysterical and 
functional pains. 

Organic joint pains may be due to injury or to disease of any 
one or more of the following structures : namely, the bone, car- 
tilage, synovia, capsules, muscles, tendons, subcutaneous tissues, 
and the skin. The pain in the bone may be due to involvement 
of the epiphysis, in which case it is elicited by direct pressure over 
the epiphysis. On the other hand, if the articular cartilage is dis- - 
eased, the pain is best elicited by suddenly jolting the articular 
cartilages, one against the other. If pain is present from the on- 
set of the swelling in a moderately enlarged joint, and then if a 
sudden enlargement of the joint occurs, with a concomitant in- 
crease of the pain, the condition is most likely a chronic arthritis, 
with an acute reinfection and consequent synovitis. If such is the 
case, it is accompanied by the symptoms found in acute synovitis, 



such as a rise of temperature, chill, and marked redness of the 
skin. If pain and swelling are found first, in an area adjacent to 



jrtRES MINOf^ 








■ Supplies skin 


Fig. 59. — Pain in Skin Over Back and Shoulder Due to Disease of 

Shoulder Joint. 

In this drawing of the brachial plexus is shown how in injuries to the shoulder 
joint the pain may be carried back through the suprascapular and circum- 
flex nerves to the anterior branch of the fifth cervical, where it is trans- 
ferred to the posterior branch of the fifth cervical and thence is further 
propagated backward until it is distributed to the skin over the back 
(trapezius muscle) . 

the joint, and then spread to the joint and cause it to become very 
much swollen, sensitive, and tender, it indicates that an inflamma- 
tory process has extended from the adjacent tissues to the joint. 


causing an acute arthritis. Inflammatory processes of this nature 
are characteristic of extension from an osteomjelitic area in the 
bone into the joint, and also of an inflammation of the adjacent 
soft parts, such as occurs in erysipelas, abscess, lymphangitis, 
and bursitis with consequent extension into the joint. 
Osteomyelitis is tender only on deep pressure, while cutaneous 
and subcutaneous inflammation is exquisitely tender on super- 
ficial pressure. Inflammatory changes also give other character- 
istic symptoms. 

Radiation of Joint Pains. — Joint pains, as a rule, do not 
radiate. There are few exceptions, however, as exemplified in the 
pain of the knee and the inner side of the leg, which occurs in 
the hip- joint disease, and the pain in the ankle and calf of the 
leg present in flat foot. Pain due to disease of the shoulder joint 
is sometimes felt in the skin over the back and shoulder (see 
Fig. 59). There may also be a radiation of pain to joints. This 
is found in primary or associated nervous lesions, as tabes or 

Intensity of the Pain. — The intensity of the pain gives some 
indication of the rate of development of the lesion, for it has been 
found that the severity of the pain depends to a great extent on 
the suddenness of the onset of the disease; the more acute the 
onset, the more severe is the pain. The reason that pain is not 
very severe in disease of gradual development is that, in this type 
of disease, the body becomes accustomed to the pathological 
changes, and is not so radically afi^ected as it would be if they were 
of sudden origin. Therefore they do not cause such sudden re- 
adjustment of tissues and consequently do not cause much pain. 
When joint pains are of extremely sudden onset, they are usually 
the result of an acute synovitis. 

Symptoms. — In involvement of a joint the pain, as a rule, is 
accompanied by certain more or less speciflc symptoms, such as 
muscular spasm, and swelling or loss of function of the part 
affected. In deep joints, as the hip, muscular spasm is the best 
indication of joint trouble; whereas, in superficial joints, as the 
knee, swelling is the surest indication. 


Tlie CESSATION OF Fuis'CTioisr in a hypersensitive joint may be 
explained on the following hypotheses : 

(1) That a balance exists between the external muscles and 
the internal resistance of a joint. When the muscular action be- 
comes excessive, and too much pressure is exerted upon the in- 
ternal structures of the joint, pain is produced. This inhibits 
further action of these same muscles, and causes inactivity. 

(2) Where excessive pressure is present, there also seems to 
be, according to Hilton, a lessened amount of synovial fluid, which 
produces more difficult movement, a tendency to pain production, 
and a consequent inhibition of motion. 

(3) Muscles surrounding or associated with, an affected or 
painful joint are hypersensitive, and are easily thrown into con- 
traction, in which etate they are better able to repel any attack 
upon the integrity of the joint. This hypersensibility also causes 
them to contract to a lighter stimulus than usual. In some cases 
the slightest touch causes the most pronounced reaction. 

(4) A position of flexion is generally taken by an affected 
joint, because even though both the flexor and the extensor muscles 
are equally involved, the flexors being the stronger, overcome the 
weaker extensors, and draw the limb into the position of flexion. 
It is possible that the associated tenderness and loss of muscular 
power present in a limb in which the joint is diseased and painful 
may be exp)lained by the association of the nerve supply of the 
joint with its surrounding muscles and overlying skin. From 
these premises Hilton has deduced the following law: The 
same trunk or nerves whose branches supply the groups of 
muscles moving a joint, furnish also a distribution of nerves to 
the skin over the insertion of the same muscles, and the interior 
of the joint receives its nerves from the same source. This law 
does not always apply, for it has been partially controverted by 

After the patient has described his pain and its characteristics 
it is necessary to verify his statements. This is done by palpation 
and manipulation. Of the symptoms resulting from manipulation 
the most important one is TEXDEKisrEss. In all inflamed joints this 


is always present. It is also well to note wliether the tenderness 
is superficial or deep. If superficial, the lesion may be in the skin, 
muscles (myalgia), or nerve (neuralgia), but if it is deep and is 
noticed only on deep palpation, it indicates that the lesion is 
probably associated with the bones forming the joint, or with the 
synovial membrane of the joint itself. Then if the tenderness is 
not too great, manipulation of the joint is performed (passive 
motion being made). Some idea of the intensity of the pain may 
be derived from the resistance to motion. Tenderness in a joint 
may also be elicited by knocking the opposing joint surfaces to- 
gether with a sudden shock. If they are denuded or inflamed, 
pain is produced. Both of these signs can be elicited in the 
presence of fluid if the quantity is not too large, or if the internal 
tension is not too great. If still in doubt as to the origin of the 
pain, it is necessary (after all these diagnostic means have been 
exhausted) to use a so-called therapeutic test. Mercury and iodin, 
as a rule, will cause syphilitic joint pains to cease, and salicylates 
ameliorate those due to rheumatism. 

Of the symptoms associated with pain in joint disease swell- 
ing of the joint and eedness are the most important. Redness 
usually is associated only with acute processes, which may be of 
two kinds: (1) traumatic, in which, in addition to swelling of the 
joint there is present a history of an injury; (2) infectious, when 
infection is added to traumatism, the pain and swelling increase 
and fever makes its appearance. If, following traumatism, there 
occur in a joint pain and swelling, it indicates that an acute 
synovitis has developed. If fever is also present, infection should 
be thought of, and septic organisms should be sought. In cases of 
subacute urethritis, the gonococcus is a frequent cause of joint in- ■ 
volvement. However, gonorrheal arthritis should always be con- 
sidered in case of an apparent idiosyncratic inflammation in the 
joint, when it is borne in mind that septic involvement of a joint, 
without external communicating injury, is very rare, and that 
when, in the presence of gonorrhea, joint involvement occurs, the 
gonococcus is probably the causal agent. In gonorrheal arthritis 
the pain is slight at first, and is accompanied by swelling and stiff- 


ness of the joint, with a slight temperature. A history of such 
joint difficulty may also show that the joint symptoms followed the 
passage of a sound. 

Eisendrath gives the order of frequency of involvement of the 
joints in eight hundred and fifty-five cases of gonorrheal joints, as 
follows: In the knee, in 158 cases; in the ankle, in 125 cases; 
in the wrist, in Y6 cases ; in the elbow, in 53 cases ; in the shoulder, 
in 44 cases ; in the hip, in 42 cases ; in the temporo-maxillary, in 
16 cases; in the small joints of the foot, in 46 cases; in the heel 
and toes, in 21 cases ; in the small joints of the hands, in 50 cases, 
and in other articulations, in 24 cases. 

Diagnosis of Inflammatory Joint Pains. — Septic. — All in- 
flammations of a joint are not septic. The presence or absence of 
infection may be denoted by the temperature of the patient. 
Fever, as a rule, is an indication of infection. Where infection is 
present, either rheumatic or septic, the original site of entrance 
should be sought. In rheumatism it frequently is the tonsils; in 
gonorrhea, the urethra ; in sepsis, the endometrium. Less fre- 
quently the infection may originate from typhoid fever, menin- 
gitis, and pneumonia. 

If the inflammation of the joint is non-septic and fever is 
absent, the metabolic and eliminating organs of the body should 
be examined. Pain and redness of a joint are very common in 
lead poisoning, joint disorders accompanying psoriasis and in the 
so-called uric acid diathesis, the sodium urate deposits in the joint 
causing pain. In children scurvy is a frequent cause of joint 
disturbance. In a suspected case of rickets the gums should be 
examined for sponginess, and the body for the hemorrhagic skin 
eruptions which are so characteristic of this disease. 

In 7-hcumaHc inflammation the pain is most severe, and is 
accompanied by an excessive degree of joint swelling. If cardiac 
involvement is also present, and a rapid amelioration takes place 
under the use of salicylates, the diagnosis is rendered certain. 
Should redness be absent and temperature little marked, tuber- 
culosis may be present. Tuberculosis of a joint (especially of the 
knee) is frequently present without redness, and in many cases 



without pain. A tuberculin reaction or tuberculous foci else- 
where in the body would aid in clearing the diagnosis. 

Acute synovitis is characterized by chills, swelling, tenderness, 
loss of motion and redness of the overlying skin. Stiffness is a 
frequent sequela of synovitis.. When it occurs, pain on motion is 
excessive. Stiffness with pain may also be the result of immobi- 
lization for long periods. 

I L. 










iNNeRSiDf : 



Fig. 60. — Obturator and Accessory Obturator. 
This shows the relation of different thigh muscles to the hip joint. 

Hip Joint.^ — In diseases of the hip joint, we have occasion 
to observe many different forms of pain, the varieties of which 
doubtless depend upon the peculiar relationship of the nerves to 
the joint. The nerves of the hip joint are mostly derived from 

^ By Dr. Werndorf , Assistant to Professor Lorenz, in Vienna. 


the lumbar plexus. They are: (1) a median skin branch from 
the femoral nerve, and (2) the obturator nerve, which through 
its posterior branch supplies the anterior and median parts of the 
capsule, and through other branches supplies the intraarticular 
ligament and the acetabulum. Many other nerves reach the hip 
joint, either by way of the nervus ischiaticus or the quadratus 
femoris from the sacral plexus. 

Radiating Pains. — The pains observed in the hip joint are, 
for the most part, either radiating or local. Radiating pains are 
observed in the early stages of all classes of hip-joint disease. 
They are frequently the first signs of the so-called voluntary lame- 
ness, and are also an early symptom of beginning tuberculous dis- 
ease of the hip. They are also observed in acute and chronic in- 
flammations of the hip joint, and in growing joints. The most 
frequent point of radiation is the knee. It is very probable that 
the pains propagated to the knee arise through suffusion into the 
obturator nerve, which runs in the immediate neighborhood of the 
joint. Indeed, the pathology of the hip joint offers an important 
point for this sort of explanation of the so-called knee pains, for 
anatomical examinations show that the synovial form (most fre- 
quent) starts with proliferating tuberculous granulation tissue in 
the acetabular fossa, and also in the part of the joint cavity occu- 
pied by the intraarticular ligament. A branch of the obturator 
nerve, supplying the joint, accompanies the ligament and enters 
the joint through the incisura acetabuli. Branches from this 
nerve also supply the upper half of the knee joint, and the median 
side of the thigh, in which locations the referred pain is most fre- 
quent. Radiating pains are frequently also felt in the lower half 
of the knee joint, or in the popliteal space. 

Functional, Pains. — Another variety of pains observed in 
the hip joint, which are of great interest, are the functional pains 
resulting from movement and weight bearing. The principal 
difference between these two forms of pain has generally been 
overlooked. Lorenz was the first to show, on the foundation of his 
interference therapy, the fundamental differences between the 
movement and the weight-bearing pains. The so-called move- 


ment pains arise on movement of the head of the bone in the artic- 
ular cavity; the weight-bearing pains, on the contrary, arise 
through the (functional) v^^eight-bearing stress on the bones con- 
. stituting the joint. 

Movement Pains. — If a synovial diseased joint is opened, the 
synovial membrane is found to be considerably swollen, it being 
three or four times thicker than normal, and, at the same time, 
reddened and infiltrated. The cartilage of the head of the bone 
may be perfectly normal. Its shining whiteness is in striking 
contrast to the redness of the synovia. ISTow, by the least move- 
ment of the head of the femur in the acetabular cavity, the dis- 
eased, and therefore very sensitive, synovial membrane is pinched 
and squeezed into folds. It soon becomes injured, and this trau- 
matism chiefly affects the numerous and multiple divisions of the 
nerves running in the synovia. Therefore the pain felt on move- 
ment occurs through the irritation of the intraarticular nerves of 
the synovial membrane. It is understood, without further ex- 
planation, that in this stage of the disease weight-bearing, that is, 
the pressing of the head of the bone against the articular cavity, 
is without pain. Therefore, on examination, very often the re- 
markable symptom occurs that a child with coxitis walks entirely 
free from pain, and that, on examination of a joint previously 
painful on to and fro motion, the weight-bearing test proves en- 
tirely negative. A light blow on the sole of the foot of the diseased 
and outstretched limb produces no pain, while the least attempt at 
movement of the thigh against the pelvis produces the most severe 
pain. The irritation (on movement) of the intraarticular nerves 
produces a reflex spasm of the muscles which surround the hip 
joint. The joint is at once, when fixed through the resulting 
muscular action, rendered free of pain, since the injury of the 
sensitive internal covering of the joint is prevented. So it hap- 
pens that a muscular fixed joint is insensitive against weight bear- 
ing, while for the same reason night cries are a constant symptom 
in the history of a coxitis patient. In sleep the muscular spasm 
which fixes the hip joint relaxes, and with it the fixation of the 
synovial membrane disappears and any involuntary movement of 


the patient produces the greatest pain. He is aroused from sleep 
bj the pains. The muscular spasms recur, and again protect the 
joint from painful movement, so that the patient again falls to 

Should any doubt remain as to the truth of this explanation of 
the causation of these pains, it will disappear on viewing the 
results of treatment by early fixation by means of a plaster cast. 

The plaster cast takes the role of the fixating muscles, and 
the joint will remain insensitive to weight bearing, so insensitive 
that the coxitis patient is able to walk on his diseased limb, and 
frequently can even jump on it without producing pain. 

Weight-hearing Pains. — The pains observed on allowing the 
hip joint to bear weight are of an entirely different kind. They 
are mostly local, are seldom radiating, and disappear if the patient 
rests in bed. Movement of the thigh of the diseased side against 
the fixed pelvis produces no noticeable increase of the pains. They 
arise through traumatism of the ligaments and muscles, as the 
result of a changed direction of weight-bearing. Therefore, they 
are almost always observed when adduction and flexion contrac- 
tions are present in the hip. When, as may frequently be observed, 
a genu valgum, or recurvatum occurs in addition to the adduction 
flexion contraction, weight-bearing pains are present in the knee 
joint. They are similar to the pains arising from static deformi- 
ties, and can be well differentiated from the radiating pains pre- 
viously mentioned. Trauma of the soft parts of the joint is caused 
by the stretching of the muscles and tendons on the adduction side 
of the joint. The bony structural inhibition itself produces very 
little pain, except when destruction of the joint itself is present. 

Physiological investigation (Dubois Raymond) has shown that 
equilibrium in walking and standing occurs not so much through 
the action of the bony elements of the joint as through the play of 
musculature related to the joint and the tension of the ligaments. 
The knowledge of these facts is of the greatest value in the treat- 
ment of a tuberculous hip joint, for it shows us that a hip joint, 
once fixed and therefore protected against joint movement, may be 
subjected to weight bearing. The functional irritation (friction) 


of the weight-bearing is suitable to stimulate the end of the bone to 
grow, and in this way to pro'duce an ankylosis of the hip joint, 
which is the object sought. 

Tension Pain of Intraarticular Hip- joint Abscess Besides 

movement and weight-bearing pains, we recognize in the hip joint 
an especial form of pain which has been observed exclusively in 
intraarticular abscess of this joint. It is classified as tension pain, 
and is produced through the progressive hypertension of the joint 
capsule, due to an increase in the intraarticular pressure. The 
pain, for this reason, may be almost unbearable. The weight- 
bearing pains are felt especially on walking, and the movement 
pains are elicited on gross movements of the joint; and while in 
both many intervals of rest are granted to the patient, the pain 
of intraarticular abscess is continuous. Pressure of the bed 
clothes alone often causes intolerable pain; and, as a rule, a 
child with an intraarticular abscess cries and screams incessantly. 
The tension pains of an intraarticular abscess defy every form of 
mechanical treatment, and it is precisely this negative result of 
an otherwise efficient therapy which gives very frequently an im- 
portant point for the diagnosis of an intraarticular abscess. How- 
ever^ the gTeatest difficulty underlies the diagnosis, especially of 
a beginning intraarticular abscess. One is unable to determine 
the presence of fluid in the joint, owing to the cavity of the hip 
joint being very slight, and because the thick, muscular infundib- 
ulum surrounding the joint makes it inaccessible to the sense of 
touch. Fluctuation is felt only after the abscess has penetrated 
the capsule and has become extraarticular. 

The diagnosis, however, can be made by close attention. A 
coxitis patient who has been treated a short time with mechanical 
treatment, that is, with the plaster trousers or the so-called com- 
bined bandage (Lorenz plaster hose with leg apparatus), may re- 
main for a short time without pain. He then commences to cry 
out a couple of times in the night, but by day he is usually free 
of pain. In a few days painful attacks occur also in the daytime ; 
the night cries become more frequent, and in a short time the 
pains are continuous, so that the patient presents a picture of 


the greatest distress. In spite of all the bandages, the pains 
increase, and evening fever sets in= This condition per- 
sists many weeks with a constantly increasing severity, nntil 
suddenly, over night, the pains entirely cease, and the very 
sick patient appears again as though given back to life. The 
intraarticular abscess has broken through and has become 
extraarticular, and will, finally, be palpable as a subcutaneous 

A little trick, which is suitable to establish objectively a 
beginning intraarticular abscess, may be brought into play. With 
the patient in an abdominal posture, normally, the medium-size 
trochanter can be touched in a small depression corresponding to 
the retrochanteric fossa. This part of the posterior and upper sur- 
face of the neck and of the femur is not normally inclosed by the 
joint capsule, but in the early stages of an intraarticular collection 
of fluid, the dilated capsule is swollen and covers the otherwise 
free and extraarticular part of the posterior part of the meek of 
the femur, so that, by close investigation, a circumscribed fluctua- 
tion may at this point be determined. 

The knowledge of the beginning of an intraarticular abscess 
is, therefore, of a sig-nificance not to be depreciated, because in a 
positive diagnosis the early opening of the joint (arthrotomy) re- 
lieves the patient with one stroke from all his suffering. 

According to William Bruce (Scottish Med. and Surg. Jour., 
1904, XIV, 297-304), gouty deposits may occur in the hip joint. 
These, he claims, irritate the articular (nerve) branch which, 
arising from the fourth, fifth L. and first S. segments, causes irri- 
tation to these segments, and gives rise to pain, referred to the 
areas of distribution of the sensory nerves derived from them. 
These areas of distribution almost coincide with the area of distri- 
bution of the pain in cases of sciatica. He differentiates the gouty 
joint from sciatica, however, in that, in this condition: (1) There 
is a wasting of the gluteal muscles. This is absent in sciatica, be- 
cause these muscles are not supplied by the sciatic nerve. (2) In a 
gouty hip joint there will also be noted impairment of motion — 
also (very frequently) a grating and roughness on movement. 


(3) There is also lameness of the hip and (4) tenderness to pres- 
sure over the hip joint. Both of these are absent in sciatica. 
These considerations also hold true for an arthritis deformans of 
the hip. In all cases, however, an X-ray picture should be taken, 
and the diagnosis made certain. 



The circulatory system consists of the heart, the arteries, 
capillaries, and the veins. The heart is considered under its ap- 
propriate heading (q. v.). At the present time we shall consider 
the blood vessels (arteries and veins). The capillaries can hardly 
be said to cause pain, except possibly in inflammatory states, vs^here 
undoubtedly they have a slight influence in giving rise to the 
throbbing pain felt in those conditions. 


In circulatory disturbances, pain is produced either by a too 
great (disproportionate) increase or decrease in the blood supply. 
When the blood is increased in quantity, congestion results, and 
pressure is made upon the terminal filaments. This congestion is 
of two varieties, namely, active and passive. The active variety 
has been considered under inflammatory pain. The passive vari- 
ety (passive congestion) we will now consider. 

Pains from Increase in Blood Supply. ^ — First of all, what is 
meant by passive congestion ? By this, we here understand a con- 
dition in which there is an excess of blood in a part, due to back- 
ward pressure. This pressure can never become excessive; so that 
the most to be expected in this condition is pain of a dull, aching 
character. This pain is always felt directly in the congested area 
or is referred to the skin region associated with the congested 
organ. In static congestion a part of the pain undoubtedly is due 
also to toxic products, which must, of necessity, accumulate in the 
tissue when the exit from the affected part is obstructed. Such 
stasis pains are produced in the liver and spleen when the right 



heart circulation fails. These are probably the two best examples 
of this condition, because in both cases inflammation can be abso- 
lutely excluded. The cause of the pain is the stretching of the 
capsule of these organs, with possibly, at the same time, some pull 
and drag on the ligaments. Of course, as a cause of passive ob- 
struction, tumors or displaced organs pressing upon the returning 
veins must not be forgotten. 

Pains from Diminution in Blood Supply. — A diminution of 
the blood supply to a part causes pain by the starvation of the 
tissues which results; and, as the nervous tissues are by far the 
most sensitive, disturbance in them is first produced, and sudden, 
sharp pain is produced. This is well illustrated in Kaynaud^s 
DISEASE^ the symptoms of which are due to a contraction of the 
smaller arterioles in an extremity (generally the hand). In this 
disease sudden, sharp pain occurs in an extremity, increasing with 
the elevation of the part. The surface is cool and white, and sen- 
sation is diminished, the part being numb to the touch. This 
symptom complex appears (and disappears) at irregular intervals, 
until finally a small, atrophic ulcer develops on the most distal 
part of the limb affected. This may progress upward, or a portion 
of a finger or toe may become gangTenous. In other cases the pri- 
mary contraction is followed by a dilatation of the vessels, and the 
part becomes swollen and purple (Sachs, 622). In these cases, 
when the limb is elevated, the pain, which is of a drawing, burn- 
ing type, disappears. Raynaud's disease — ^which is, after all, a 
fairly ample syndrome — is in reality a dual affair. The cells in 
the spinal cord, usually termed sympathetic and trophic, and regu- 
lating the vessels, are those primarily affected. The pains are 
largely due to implication of this system of nerves, and are 
grouped by Head with the general group of protopathic and deep 
sensibility pains. Buerger has recently described a state in which 
the arteries of the lower limbs become thrombosed or obliterated 
(endarteritis obliterans. See intermittent claudication.). Here the 
pain is most intense and is constant while the limb is dependent, 
but disappears on the elevation of the limb. ISTo medicinal treat- 
ment can alleviate the pain of the unfortunate sufferer, and the only 


means of easing his agony is high amputation of the diseased limb. 
This condition has been called thrombo-endarteritis obliterans. 

In PUKPUEA H.TSMOKRHAGiCA the pain is also caused by obstruc- 
tion to the onward circulation. The cause can be explained more 
explicitly if we examine the cause of the hemorrhage in a case of 
purpura hasmorrhagica due to syphilis (reported by Sabrazes and 
Duperin, 573). In this case the hemorrhages were due to the 
rupture of capillaries, due to mechanical obstruction by the intes- 
tinal granulomatous lesions of the disease. These lesions will ex- 
plain the pain felt in these conditions, for it is a noticeable fact 
that the pain, not only in this, but in most rheumatic purpuras,^ is 
very great until the hemorrhage appears, when it is eased. In 
other words, during the period of distention of the vessel, there is 
pain, while on rupture and removal of the intraarterial tension the 
pain disappears. In any case, when an artery is affected, the pain 
follows the distribution area of the affected artery. 

Functional activity^ because of the increased demand made 
upon the arterial system, often causes severe pain when the blood 
supply to the active part is deficient. This is illustrated in cases 
of aortitis, stenosis of the coronaries, passive cougestion of the 
liver and spleen, and in arteriosclerosis of the mesenteric vessels. 


The principal arterial diseases causing pain are arteritis, 
thrombosis, embolism and aneurysm. It has been claimed by 
Granville that the vasomotor nerves have a component of sensory 
fibers. Should such be the case, one can easily understand why, 
in disturbances of the vessels, pain should result. That a comple- 
ment of sensory fibers accompany vasomotor nerves may in part 
be true, for in performing _ abdominal operations under a local 
anesthetic, it has been found that the ligating of vessels is very 
painful. Yet it seems that, in most cases,' especially in the pres- 
ence of inflammation of the vessels, the pain is due to the in- 

1 1 am not aware of any work done as yet which would prove that the 
cause of obstruction of the vessels in purpura hsemorrhagica is either emboli 
or thrombi, but reasoning from analogy such would seem to be the case. 


flammation which has extended to the adjacent nerves. This has 
been set forth by Buch as the cause of pain in aortitis. 

Inflammation. — When inflammation occurs in an artery the 
tima is the part first affected. Up to this point no pain results; 
then the inflammation spreads to the media, and finally to the ad- 
ventitia, in which it seems that the receptors for pain sensibility 
may lie. The arteries of smaller caliber are not as sensitive as the 
larger ones. Perhaps the best place to study arterial changes and 
the sensory results is in the aorta. Here the inflammation, as long 
as it remains in the aorta, produces no pain, but it soon passes out 
and involves the neighboring cords of the sympathetic. Ordinarily 
the sympathetic is not painful, but, according to Buch (171), 
Wutzler, riourens, Bruchet, Valentin, and Longet have found 
that the sympathetic becomes sensitive through inflammation or 
congestion. Confirmation of the fact that inflammation may be 
communicated to the sympathetic from an aortitis can be found in 
the writings of Debove and Letulle (384), Eigal and Juhel-Kinon 
(385), Weber (386), Lanceraux (387), Dutil and Lanny (388), 
Lapinsky (389), Duplaix (390), and Holsti (391), who have 
found that inflammation of the aorta was communicated through 
the adventitial coat to the aortic and celiac plexus. Buch agrees 
with these observers, and discredits the view of Potain (380) that 
the pain is due to inflammation of the arterial wall. Engleman 
(381), like the previous observers, believes that the pain is due to 
hyperalgia of the aortic plexus. Buch (p. 291), in affirming these 
views, claims that he not only has found the aorta hyperalgesic, 
but also the two bordering sympathetic cords, or at least one of 

The pain of aortitis is sudden in onset, occurs in the epigas-- 
trium, and resembles angina pectoris in its severity and sudden- 
ness. It is produced by exertion and by the ingestion of food, the 
kind seeming not to be so important as the quantity. The pain 
comes on in paroxysms, each individual paroxysm lasting only a 
few minutes. Paroxysms seem to be especially produced by eleva- 
tion of the arterial pressure, particularly when it is accompanied 
by contraction of the superficial vessels. A cause of this contrac- 


tion may be excessive functioning of the suprarenals (Buch). In 
this relation it seems that when the blood is thrown into the deeper 
vessels because of their stiffness they are unable to dilate and 
accommodate it. As a consequence, congestion of the sympathetic 
occurs. This gives rise to pain, because of its previous irritability. 
A reflex dilatation of the vessels then takes place, change of the 
blood flow occurs, and the congestion and pain are relieved. It is 
characteristic of these cases that the pain is relieved by strophan- 
thus or diuretin. 

The time of onset is variable, and often seems to be the result 
of exertion. Yet exertion is not the cause, in all cases, for, in some 
instances, the pain appears in the middle of the night while the 
patient is sleeping quietly. The position of the body of the patient 
seems to make a difference only in an individual case. With some, 
the pain comes on when they are standing, w^hile with others it 
appears when they are lying down (Brunton, 11). Kreuzfuchs 
(572) claims that the pain is most liable to develop when the 
patient is lying down. Brunton calls attention to the distention of 
the bowel with flatus, which frequently comes on some time 
during the attack. During the attack tenderness of the aorta and 
neighboring nerve trunks is present, and, according to Brooks (93, 
p. 784), persists for some time afterward. 

In some cases, as related by Rossback (623), symptoms of 
gastric disturbances may be present for years without a typical 
attack. These are the cases which are frequently diagnosed as 
stomach disorders. Arteriosclerosis of the aorta seems to be more 
common in men than in women, and most frequent in the years 
from forty to fifty. 

Increase of Blood Pressure. ^ — That increase of blood pressure 
alone may cause pain is affirmed by Pal (674), who, in examining 
cases of lead colic, found the blood pressure in the intestinal ves- 
sels increased from one-half to twice the normal pressure. This 
increased pressure irritates the terminal nerve filaments, or re- 
duces the circulation in the intestine, thus causing pain. 

Intermittent Claudication. — There is a peculiar and compara- 
tively rare condition, especially - frequent in male Russian 


Hebrews, in which pain in the lower limbs is associated with vas- 
cular alterations. It was first described bj Charcot. There is, in 
this disorder, a sensation of numbness, fatigue and pain, which 
comes on in one or both legs on walking. It increases in severity 
after a short time — fifteen minutes to half an hour — and renders 
locomotion impossible. On resting, the pain disappears, to ap- 
pear again after walking. In advanced cases the pains occur 
spontaneously, from time to time, or they are persistent. 

The pains resemble* those of a sciatica, although they are apt 
to be more diffuse, involving the entire calf, or thigh, rather than 
following a nerve trunk. Cyanosis, pallor and coldness are fre- 
quent accompanying symptoms. They can be induced by having 
the patient walk briskly, when the sole of the foot will be observed 
to be waxy and cold. The absence of pulsation in the dorsalis 
pedis and posterior tibial arteries is a marked feature of many 
cases. Arteriosclerosis is a constant accompaniment, and X-ray 
examinations of the legs will often show the presence of hardened 
calcified blood vessels. An obliterating arteritis alters the nutri- 
tion of the muscles and may be the cause of the pain on walking. 

At times a spastic vascular condition may rest at the bottom of 
the disorder without any pronounced organic vascular lesions, 
although these are probably early cases. It may also be due 
to eongenitally small blood vessels. In the majority of these cases 
the organic vascular changes come along later. 

An intermittent claudication of the arm may be present. 

Erythromelalgia. — Here the chief features are pain and red- 
ness of the skin, particularly of the feet, less often of the hands, 
still more rarely of all four extremities. Pain is an early sign. It 
comes on after over-exertion, and is usually abrupt in onset, al- 
though occasionally gradual in its development. The balls of the 
toes and the heels are the sites of maximum involvement. Rarely 
the whole extremity, upper or lower, is invaded. There is, in addi- 
tion to the pain, redness, and the tips of the fingers or toes are 
swollen. There is a sensation of exquisite pain, with burning, 
and, as a matter of fact, the local temperature is raised. The 
blood vessels pulsate, small nodules appear, and marked sweating 


is apparent. Other sensory changes are slight, and consist of a 
mild hj]3eresthesia or hypesthesia. 

The pain varies. In the more advanced cases it is severe tor- 
ture, but may vary from a mild discomfort to agonizing pain. 
Cold and the recumbent posture relieve it, v^hile lowering the af- 
fected part, standing or walking (if the feet are affected), or the 
application of heat, increase its severity. On walking (feet be- 
ing affected), the swelling is increased, and the redness becomes 
successively more marked. 

This condition is probably more than a single entity, since it 
may be associated with disease of the sympathetic cells (in the 
cord), or with disease of the peripheral nerves. Again it is allied 
with vascular disorders. It is probably a vasomotor neurosis of 
central origin. 

Embolism and Thrombosis of the Mesenteric Arteries. — The 
mesenteric arteries merit separate consideration; and it is espe- 
cially necessary to review the two most important causes of pain 
in lesions of these vessels, namely, thrombosis and embolism. 

In both of these conditions the blood supply to the intestine is 
cut off and paralysis (absence of peristalsis) occurs in the affected 
segment of the bowel. This paralyzed bowel acts as a barrier to 
the forward movement of the feces, and all the signs and symptoms 
of obstruction take place. In embolism these symptoms are, as a 
rule, sudden in onset, while in thrombosis they develop more 
slowly. As in intestinal obstruction from other causes, generally 
the first sign of the disease is pain, which is sudden, sharp, acute, 
and is referred to the epigastrium, if the superior mesenteric ar- 
tery is affected, while if the inferior is the one involved, the pain 
is referred to the region of the abdomen, below the umbilicus. 
Shock is a constant symptom, accompanying the pain. After the 
first acute pain, there is often a lulling of the pain-sensation, but 
the pulse continues rapid (the effect of the shock). In a short time 
the pain again becomes prominent, and is of a colicky character. 
The primary pain is regarded as due to the sudden shock to the 
mesenteric nerves, the secondary as due to the pull and drag upon 
tlie mesentery. As soon as the segmental bowel paralysis becomes 


complete, signs of oLstnictioii, sueli as vomiting, intervene. The 
vomitus consists, at first, of the contents of the stomach ; later, 
of the bowel down to the point where the obstruction has occurred. 
The bowel movements at this time often contain blood, which is 
bright scarlet and somewhat fluid, in obstruction of the inferior 
mesenteric. It is dark in color and somewhat clotted in lesions of 
the superior mesenteric artery. A tumor composed of gas also 
makes its appearance in the abdomen. This tumor is generally 
more marked on the left side in lesions of the superior mesenteric, 
while in lesions of the inferior mesenteric it is more marked on 
the right side and across the abdomen. This tumor mass quickly 
becomes of great extent, and soon occupies the entire abdomen. At 
the same time a transudation takes place, and on celiotomy a 
bloody peritoneal fluid is found. Should the obstruction be more 
gradual, such as occurs from an arteriosclerosis, pain is a marked 
symptom. It is not constant, but is of a flitting character, such 
as we find present in another location in angina pectoris. Pain 
of this character, without any well-defined, apparent pathology, 
should always cause us to examine the arterial system for arterio- 

Aneurysm. — When the coats of an artery are abnormally di- 
lated, singly or en masse, we have a condition called aneurysm. In 
this the pain is constant and gnawing as a rule. In some cases it 
is paroxysmal, though often in the early stages of aneurysm it may 
be entirely absent. In many cases the patient localizes the pain 
over the tumor mass by pressing over the affected area with his 
hand; and a characteristic of the disease is that deep pressure is 
always very grateful. Should any sensory nerves be pressed upon 
by the tumor mass, jjain is referred to their peripheral distribu- 
tions. These referred pains vary with the situation of the tumor. 
When the arch of the aorta is involved, the local pain is felt to the 
right of the sternum at about the junction of the second or third 
rib with the sternum, and the referred pain is felt in the inner side 
of the right arm, and extends as far down as the elbow. Fre- 
quently in an aneurysm of the thoracic aorta the pain does not 
follow the distribution of the intercostal nerves, but is located over 


the back in the distribution area of the spinal nerves. It may also 
radiate into the left shoulder and arm. The aneurysms of the 
thoracic aorta, however, do not produce as much pain as do those 
of the abdominal aorta. In this latter pain is very severe, and is 
felt in the back, as a rule. At first it is somewhat paroxysmal, and 
then takes on a dull, boring character. When this occurs, the diag- 
nosis of bony involvement may be made with absolute certainty. 
Certain positions, namely, those in which pressure is made upon 
the vertebrae, cause extreme, almost unbearable, pain. Hyperal- 
gesia, corresponding to Head's zones, is often present. These 
areas of hyperalgesia should be carefully sought for and mapped 
out. In all cases of suspected aneurysm careful inquiry should be 
made as to the presence of pain, because the patient frequently 
neglects to mention it. 


The lesions of the veins causing pain are inflammation, throm- 
bosis and varices. 

Inflammation of the Veins. — Inflammation of the veins (phle- 
bitis) causes a very severe pain, which is more likely due to an 
associated involvement of the surrounding tissues than to the in- 
flammation in the vein itself. Nevertheless, irrespective of the 
cause, the pain is most severe, constant and aching in character, 
and is greatest when the limb is in the dependent position. The 
pain is increased by pressure. By means of the tenderness on 
pressure, the entire distribution area of the vein can be defined. 
Phlebitis is very common in the femoral distribution following 
child-birth, during which a slight infection of the iliac vein has 
taken place. It is also very frequent in the femoral veins follow- 
ing typhoid fever. When so affected, the patient voluntarily lies still, 
because the pain is increased by the slightest movement. The con- 
dition persists for a varying period of time, and then disappears, 
although slight soreness lasts for some time. In some cases of 
phlebitis, the pain is referred to distant areas. This is due either 
to pressure on an adjacent nerve by the inflamed vein, or to a 


communicated infection. In cases of pressure or inflammation of 
the sciatic, or of the lumbosacral cord, the pain is referred into 
the area of distribution of the sciatic (Peterson, 625). It is most 
intractable, and is curable only on the amelioration of the causa- 
tive lesion. 

Thrombosis.- — Since thrombosis of a vein is, in nearly all 
cases, nothing more than an inflammatory process, the above de- 
scription of phlebitis will equally well apply to it. 

Varicose Veins. ■ — Of varicosities it is only necessary to speak 
of those of the lower extremities. Varicosities in other regions 
are entirely, or almost entirely, painless. When varicosities occur 
in the lower extremities, the external and internal saphenous are 
the veins principally afi^ected ; and it seems that the internal is, as 
a rule, more severely involved than the external. Consequently, 
the local symptoms will be more marked on the inner than on the 
outer side of the leg. This agrees well with the histories, for 
most of the patients complain of pain beginning above the knee 
and running around to the inner side of the leg, thence down on 
the posterior surface of the calf, extending, in some cases, even as 
far as the ball of the foot. Usually the pain is worse at night. 
During the day the patient, as a rule, has been standing on his feet 
more or less, and a certain amount of inflammatory congestion re- 
sults from this. In many cases of varicosities of the internal 
saphenous if pressure be made on the anterior crural, pain radiat- 
ing into the inner half of the thigh and the leg will be felt. After 
the formation of an ulcer, the pains are very severe, and make the 
patient's life miserable. They are eased by the application of 
firm pressure, which would seem to indicate that they are due 
either to traction from the excessive granulations, which, when 
filled, drag upon and stretch the terminal nerve filaments, or to 
exposure of the nerve endings in the floor of the ulcer, which 
follows upon the removal of the ordinary protective layers of the 
skin. In any case the pain is extremely severe and is much worse 
when the limbs are in a dependent position. 



The Glands. — The principal glandular structures are the 
glands with ducts, as the mammary and those found in the ali- 
mentary tract (salivary, pancreas), and those without a duct, the 
so-called ductless glands, as the lymphatic glands, the thymus, 
thyroid, pituitary and the adrenals. There are also numerous 
small secreting glands found in the mucous lining of the alimen- 
tary, respiratory and genitourinary systems, but these are of such 
minor importance that they do not merit a consideration. When 
pain is located in a glandular structure, it is due, as a rule, to dis- 
tention of the capsule of the gland. This distention, in its turn, 
is usually the result of inflammation. 

In those cases in which distention has occurred gradually pain 
may be absent. As a rule, it is present only when the distention is 
acute. The pain of large, glandular abscesses or of tumors of the 
glands is further increased by the pressure of the tumor mass 
upon adjacent organs or nerves. In case of pressure upon nerves, 
the pain is referred, as a rule, to the peripheral distribution area 
of the nerve or nerves involved. 

A special consideration of the most important of the glandular 
structures is in order. We shall commence with the mammary 
gland, after which we shall consider the adrenals, mesenteric, thy- 
mus, and thyroid. 

The Mammary Gland. — The mammary gland is situated in 
the lower part of the anterior lateral surface of the thorax. The 
sensory receptors of the gland are found in the alveoli, from which 
the fibers collect to ultimately join the fourth, fifth and sixth 



intercostals, in which they run to the cord. The sympathetic 
associations are with the thoracic branches. The skin over the 
gland receives its nerve supply from: (1) the supraclavicular 
branches of the cervical plexus, and (2) the anterior and lateral 
cutaneous branches of the second to the fifth intercostals. 

Pains in the breast may occur at certain physiological periods 
of a woman's life, such as in infancy (shortly after birth), pu- 
berty, during menstruation, and at the beginning of pregTiancy. 
These pains may be jDure reflex, or rather transferred, pains, and 
are probably due to stimuli carried through the nervous system, 
probably by the same well-defined paths through which other 
stimuli are carried when, in pregnancy, the breast begins to per- 
form its function, and lactation commences. It is a moot question 
whether there is, or is not, objective cause for this phenomenon, 
for it seems that the stimuli transferred to the breast from the 
genital organs cause some slight tumescence in the breast, prob- 
ably enough to produce a subjective sensation of pain, but not 
enough to be perceived objectively. A peculiar thing about this 
pain, which seems to verify its nervous genesis, is that it may be 
spread over a wide area, so that it sometimes involves the side of 
the thorax and the arm. This might be accounted for by the over- 
flow phenomenon which has been described in a previous chapter. 
The intensity of the pain varies from a slight, hardly noticeable 
sensation, to one of most intense distress. The hyperalgia is not 
always confined to one breast, but may involve both. In the 
newly-born infant, an inflammatory change sometimes occurs in 
the breast. This is probably painful, but we have no means of 
drawing positive conclusions. (See Uterus and Mammary Pain in 
Uterine Disease.) 

Pain in the breast may be due to the following pathologic 
causes : 

(1) Inflammation: (a) lactation mastitis; (b) stagnation 
mastitis ; (c) pyogenic mastitis (extension from neighboring struc- 
tures, lymphatics, blood) ; (d) small abscesses which form in 
the areola from a fissured nipple. 

(2) New growths: (a) malig-nant, as in carcinoma and sar- 


coma (pain and tenderness are not marked, but mav he present 
periodically); (b) benign, as fibroids. 

Tuni(.)rs of I lie breast, as a rule, dd iiol p,ive rise to referred 
pain. Fissnre of the nipple is very painfnl, the same as is a 
fissure at any of the other openings of the body ; for example, 
the anns, the month, or the nrethra. Simple cysts of the breast 
generally give rise to considerable pain, especially if they are of 
rapid growth. 

Most of the pain produced by mammary changes is local, but 
retention of milk, suckling (forcible), and pulling on the nipple 
often give rise to referred pain in the area of the fourth and fifth 
dorsal segment. It seems to be an invariable rule that traction 
upon the nipple produces pain over the angle of the scapula pos- 
teriorly. Sometimes it is referred along the side to the anterior 
part of the chest, and is felt beneath the breast. 

Pain and discomfort during menstrual periods should cause 
the diag-nosis to lean toward mastitis. Carcinoma in the early 
stages is generally not tender, while mastitis, as a general rule, is 

The breast may also be subject to referred pain from the 
female sexual organs, for which see p. 715. 

The Adrenals.- — The most common, in fact the only, condition 
in the adrenals which w^e are sure of as a cause of pain is hemor- 
rhage. The hemorrhage comes on suddenly and causes a great dis- 
tention of the capsule of the gland. This, of course, produces 
pain, sudden in onset, and most intense. It is, as a rule, localized 
in the epigastrium, but may radiate to the hypochondrium, or to 
the lower abdomen. Digestive disturbances in the form of per- 
sistent vomiting and diarrhea are associated with this pain, while 
at the same time a fall of blood pressure, rapid, weak pulse, and 
reduction in temperature occur. The skin gradually assumes a 
yellowish or brownish color. Debility, coma and death finally 
ensue. In regard to the debility, Murdoek (627), quoting from 
Xeusser, says that the "permanent sense of weakness and exhaus- 
tion, the lack of power and debility frequently present a striking 
contrast to the relatively good general appearance and the abun- 




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dance of abdominal fat." On examination of the abdominal wall 
one is sometimes impressed with the excessive tenderness which is 

The Mesenteric Glands. — The mesenteric glands, even though 
enlarged, do not of themselves cause much pain, unless the enlarge- 
ment is excessive, when, bj encroachment upon neighboring struc- 
tures and interference with their function, they may indirectly 
be the cause of pain production. In tuberculosis, when the mesen- 
teric glands reach an enormous size, the patient often complains 
of aching and distress, or, as frequently expressed by negro sub- 
jects, "a. misery in the abdomen." This misery becomes an acute 
pain, should the gland, becoming degenerated and caseous, sud- 
denly rupture and cast its contents into the peritoneal cavity. The 
pain now assumes the characteristics of that due to general peri- 
toneal irritation. 

The Thymus and Thyroid.— The thymus and thyroid are en- 
tirely without pain production, unless they become acutely in- 
flamed, when pain phenomena appear. Frequently in thyroid 
tumors and in disease of the gland pain is felt in the occiput, in 
the shoulder and back of the ear, due to irritation (pressure) of 
the posterior auricular. In one case pain was complained of over 
the second dorsal spine. 

In Hodgkin's disease pain in the arms is very common, be- 
cause of the pressure exerted upon the nerves in the axilla. In 
the same way pain may be felt in the lower limbs from pressure 
upon the anterior crural nerve by enlarged inguinal glands. 




As an aid to a quick orientation of the cause of pain which is 
felt in a special area, the body ma v be divided into different re- 
gions, as the head, neck, arms, chest, abdomen, and the extremities. 
Each of these "u-ill be fully discussed under special headings, but 
at first a brief, general review of the different pains in these 
regions and their significance will be undertaken. 


The head is a most important localizing center for pain, for it 
seems that here all the aches and ills of the human body converge 
to bring torment and suffering to the unfortunate individual. 
Head pain is partially considered under headache, which includes 
the pains felt in the cranial part of the head, but headaches do 
not include face pains. These are very important, as they in- 
clude one of the most sinister of all human ills, namely, trigeminal 
neuralgia (tic douloureux). Its pains occur in the forehead, the 
cheek and over the lower jaws. There are well-defined spots of 
maximum tenderness, which are shown in the drawings. Of 
other important causes of face pains, sinus disease probably ranks 
next. These sinus diseases include the frontal, ethmoid and an- 
trum of Highmore. When any of these structures is affected, 
pain is complained of by the patient, and at the same time tender- 
ness is marked over the diseased area. Should tenderness not be 
present in the area in which the ])atient complains of pain, it 
indicates that the pain is a referred pain from some distant region. 


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A good example of this is pain in the temples, referred from 
carious teeth. Reference to Figures 61 and 62 will do more to 
localize these different pain areas and their significance than an 
entire volume of description. Head pains referred (reflected) 

Mental tire 
Infectious diseases 




Brain tumor 



Inf. dental branch 

Fig. 62. — Pain Areas in the Head. 

Uterine disease 
Ovarian disease 
Migraine man- 
ner of radia- 
Ethmoid. Ar- 
rows indicate 
the direction 
of radiation 
Orbital headache 
Typhoid fever 
Eye strain 

Inflammation of 
Point of ten- 
derness in in- 
f r a-o r b i t a 1 
Antrum disease 

Point of tender- 
ness in mental 
Periostitis inf. 

from abdominal and thoracic organs are described in the chapters 
under their respective headings. 

The most important of the local head pains is headache, or, 
as it should be called, head pain. When a patient complains of 
headache, he should always be asked, '^Is it a pain, or is it only a . 
sense of pressure ?" If it is a sense of pressure, the consideration 
will be entirely different from that of true head pain. 

Sense of Pressure in Head. — Edinger has graphically dis- 
cussed this condition, especially in its relation to neurasthenia. He 
notes that "the pressure is felt in the top of the head, and is espe- 
cially severe in the morning. It generally continues all day, 
though it may lessen toward night. This head pressure, which is 


not a pain, is particularly a characteristic of tired persons; those 
who have overworked, either physically or mentally, and those 
whose hours of labor are too long or too continuous ; those who are 
hereditarily weak ; and those wlio have suffered from severe dis- 
ease (influenza) and have exerted themselves too soon thereafter. 

If the sensation is described by the patient as a pain, head- 
aches should then be considered. 

Head Pain. — In the diagnosis of headache it is well to ascer- 
tain first whether the pain is unilateral or bilateral. If it is bi- 
lateral, it generally is an indication that the underlying cause 
is of systemic origin, while if it is unilateral, as a rule it is an in- 
dication that the cause or causes acting to produce it are also uni- 
lateral in their origin. Where headache is unilateral, it is always 
wise, before making a more extended search, to examine the head 
for local causes, such as inflammations, or to examine the organs 
located in or associated with the skull, such as the eye, the ear, the 
nose, the teeth, and also the throat, which in many cases is at 

The following outline of the principal causes of head pain 
may be of value in the diagnosis. The classification 
used is based upon an anatomico-physiologic basis. Accord- 
ing to this, head pains may be divided into two great 
classes: (1) those of extracranial origin, and (2) those of 
intracranial origin. 

Head Pains of Extracranial Origin. — Extracranial head pains 
are caused by lesions of the skin, muscles, tendons, bones, and 
nerves. The shin includes the epidermis and subcutaneous tis- 
sues, and is the seat of pain in neuralgia and superficial inflam- 
matory lesions. Excessive weight of hair may be the cause of 
severe and chronic headache. 

The muscles are the seat of pains, the result of such metabolic 
disorders as occur in rheumatism, gout and diabetes. Inflamma- 
tion likewise may be a cause of local pain. In this connection 
it is well to mention a condition described by many writers, in 
which headache is due to indurative processes, occurring in the 
muscles of the head and neck. Edinger claims that, though 



almost unknown, the indurative variety of head pain is probably 
the most common of all headaches. In those suffering from it, it 
is found that at the insertions, or within the bodies of the muscles 
of the head and neck, there appears a thickening which at first is 
transient and then later becomes constant. This thickening, prob- 
ably of chronic inflammatory 
origin, irritates the sensory 
nerve fibers supplying the 
part, and thus produces pain. 
The pain occurs in parox- 
ysms, which may be brought 
on by emotional disturbances, 
physical or mental fatigue, 
sudden exposure to cold, in- 
sufficient drying after wash- 
ing the hair, a stay in bad- 
ly ventilated places, and the 
approach of damp or chilly 
weather or storms. The par- 
oxysms are least common in 
summer and most frequent 
Fig. 63.— Figure Illustrating the in the fall and the spring. 
Places Where Induration Takes j^ ^he development of the 
Place. . ^ . , 

These areas are tender to pressure. induration three stages can 

be defined. In the first stage 
a swelling of a soft, yielding consistency, often present in the 
bodies of the muscles, makes its appearance. A pufiiness to the 
touch is now felt at this jDoint ; then, in a short time, a slightly 
elastic resistance develops, as though some organization had taken 
place; and finally an induration, in which there is an absence of 
elasticity, occurs. Organization has now advanced to the stage 
at which a substance of cartilaginous consistency presents itseK to 
the examiner. The older these thickenings are, the harder they 
become and the more resistant they are to treatment. 

The symptoms are characteristic. Attacks of pain occur, 
which at first are slight and infrequent, and then gradually be- 


come more frequent, greater in severity and longer in duration. 
Sometimes thej are of a dull, aching type, and are almost con- 
stant; again, they are sharp and fleeting. They occur in various 
parts of the head, the location depending upon the site of the 
local enlargements, over which they are usually found. They may, 
however, radiate to other parts. Local pressure often gives relief. 
Before an attack the enlargements become swollen and sensitive. 

The symptoms associated with this disorder are the marked 
susceptibility of the patient to colds, depression of spirits, and to 
mental torpor. Gastrointestinal disturbances, toxic in character, 
occur, and spasms in the leg-muscles and myalgia in different 
parts of the body take place. Hypersensitiveness of the teeth and 
a pyorrhea alveolaris are also seen, and on forcible twisting or 
turning of the neck there is intense pain at the insertions or along 
the bodies of the neck-muscles. Local tenderness over the sites of 
the enlargements almost always is present. It is most common 
at the insertions of the trapezii, scaleni, splenii and sternomastoid 
muscles. Hypersensitive points are often found round the base 
of the skull, from one mastoid process to the other, and on the 
spinous jDrocess of the cervical vertebrse, particularly the upper 
cervical vertebrae. The supraorbital region also is often involved. 

These indurative headaches are to be diagnosed from: (1) 
Meningitis, in which fever is present and induration and hyper- 
sensitiveness are absent. 

(2) Migraine, in which sensitive aura are present, indura- 
tion and local hypersensitiveness are absent, nausea and vomiting 
are present, and no relief comes from massage. While hereditary 
migraine begins in early youth, indurative headache appears in 
later life. 

(3) Bone diseases, such as inflammation, caries, gummata 
and tuberculosis should also be carefully diagnosed, as they often 
give rise to local head" pain and indurative areas. A careful study 
of the general symptom-complex will often clarify the situation. 
As a rule, though, the indurative headaches are verv common. 
They are very easy to differentiate, because of their local 


That long-continued contraction of a group of head-muscles 
may cause pain is possible. Thompson (630) describes such 
headaches which arise from the long-continued contraction of the 
occipito-frontalis muscle, as the result of a strong sensory impres- 
sion, coming from the eyes, ears, or other channels of sensation. 
They may, however, be produced only as a result of the irritation 
of cold and strong winds. 

Nerves. — The head pains due to nerve involvement are to be 
classed under neuralgias and neuri tides. There is also a local 
irritation which has not progressed to the stage of inflammation. 

ISTeuralgia, which means nerve pain (for a complete descrip- 
tion see under JSTeuralgia), is a rather frequent cause of pain in 
the head. In it pressure points can be found, corresponding to 
the emergence of sensory nerves from the skull. The nerves most 
frequently involved are the trigeminal and the cervico-occipital 
branches of the cervical plexus. ISTeuralgia is frequently the result 
of wasting diseases, malnutrition, exposure, poor hygienic condi- 
tions, rheumatism, gout, diabetes, anemia, chronic malaria and 
acute infectious disease. 

ITeuritis, a somewhat allied condition, differs from neuralgia 
in being a much more active inflammation of the nerves or nerve 
sheaths. In it the nerve is painful to pressure, muscular twi tell- 
ings occur, and, if the condition continues long enough, a final 
atrophy and paralysis of the related muscles may result. 

Head pain may also be induced by the products of metabolism, 
which act locally upon the muscles of the scalp and produce pain 
by irritation of the sensory nerves in the same manner as it is 
produced in gout and rheumatism. Especially is this liable to 
happen should the resistance of the muscles have been previously ■ 
reduced by exposure to cold or drafts. In neuralgias and inflam- 
mations there is always a certain amount of associated hyperes- 
thesia,' the affected part being, in many cases, exquisitely tender. 

In addition to headaches due to local causes are those which 
are the result of conditions present at a distance from the area in 
which pain is felt. These are classified as projected, reflex, or re- 
ferred headaches. Projected headache is the result of pressure 


upon the cranial nerves, either in their extracranial or intra- 
cranial course. Such pressure may be due to tumors, caries of 
bone (especially caries or periostitis of the bone at the foramina 
of exit) and to foreign bodies. 

Reflex headache is due to a stimulus carried through the 
nervous system from some distant organ. In these headaches the 
action is upon the nerve centers, or nerves, either indirectly 
through adjacent nerve centers, or directly by the action of irri- 
tating bodies (toxins of disease and organic or inorganic 
poisons). The fifth nerve seems to be especially subject to irri- 
tation from extraneous causes, and the part that seems to be most 
commonly affected is the Gasserian ganglion. 

Referred headache is the result of a reference of stimuli along 
associated or related nerve pathways, as is exemplified in the 
frontal headache following immediately after the drinking of ice- 
water, etc. 

Head Pains of Inteacranial, Origin. — The intracranial 
causes of headache are : Meningeal changes, functional and or- 
ganic; cerebral toxemia; cerebral anemia; cerebral congestion; 
increase of cerebrospinal fluid. 

Meninges as a Cause of Headache.- — Stretching and pressure 
exerted on the meninges is the most important cause of headache,^ 
and produces the most severe and persistent pain, as in cere- 
bral tumor ; here, owing to the general increase of pressure from 
the growth, the headache is apt to be diffuse. However, when 
the cortex membranes are involved, the pain becomes localized ; 
and this localization is of the utmost value in defining the site of 
the tumor. 

The general cause of meningeal stretching and traction is 
pressure from underlying structures. The piaarachnoid is prob- 
ably not supplied with sensory nerves, and it is very likely that 
its only nerve supply consists of those supplying the blood vessels. 
Therefore, in cases of leptomeningitis, it is the congestion inci- 

1 The meninges seem to be almost insensitive to the ordinary stimuli, 
as when the skull is opened under local anesthesiae they may be touched, 
pinched or cut, without the patient complaining much of pain. 


dental to the inflammation that causes pressure upon the dura 
and its nerve filaments, and so produces pain. 

Stretching and pressure on the meninges may also be caused 
by an increase in the cubical contents of the cranial cavity, such 
as occurs by an increase in the brain substance from new growths, 
abscesses, and increase in the fluids of the brain (blood and cere- 
brospinal fluid). 

Increase in brain substance is found in new growths, such as 
tumors of the brain. These cause pain by increasing the intra- 
cranial pressure. This they do in two ways: (a) by an increase 
in the intracranial contents, which, owing to the pressure of their 
mass, cause an increase in the intraventricular pressure, and (b) 
by raising the intraventricular pressure, either by shutting off 
the means of exit of the intraventricular fluid by blocking the 
foramina of communication between the ventricles and the suba- 
rachnoid spaces, or else, by pressure on the veins of Galen. A 
loose fibroma in the lateral ventricle may also act as a plug and 
thus prevent the escape of cerebrospinal fluid, and cause intoler- 
able headache, optic neuritis, coma and death. 

Pain, in some cases, in which the tumor is cortical or sub- 
cortical, is produced by the growth pressing directly upon the 
meninges, and in this way squeezing the terminal nerve filaments 
incorporated in its substance. Tumors of the posterior fossa of 
the cranium probably cause the most pain. 

Diagnostic symptoms of tumors of the brain are pain, which, 
in cerebral tumor, owing to the general increase of blood pressure 
from the gTowth, is as a rule diffused. When the cortex mem- 
branes are involved, the pain becomes localized, and this locali- 
zation is of the utmost value in defining the site of the lesion. 
When the pain becomes circumscribed, it is most often confined 
to the forehead or to the occipital region. Accompanying the pain 
there are disturbance of sensation and motion, choked disc, rigidity 
of the pupils, vomiting of a projectile character (with an entire 
absence of gastric symptoms) and dizziness. Sometimes symp- 
toms of headache may be almost entirely absent in brain tumor, 
as in a case reported by Edinger, in which, on autopsy, a tumor 


was found in the Island of Reil of a patient, who had had head- 
ache only a short time before death. 

Brain tumors may be syphilitic, tuberculous, hydatid, carci- 
nomatous, sarcomatous, or osseous formations within the cranial 

Brain abscess causes headache in the same manner as do 

Orga^iic Meningeal Changes. — Organic meningeal changes 
due to adhesions, inflammations and hemorrhages cause head- 
aches. Adhesions between the dura and the cranium are often 
the cause of severe pain, localized over the affected area. Local- 
ized head pain may also be caused by syphilis and trauma, or it 
may be the result of inflammation. The inflammations causing 
these headaches are of two types : 

(1) Pachymeningitis interna, which is very common in old 
people, and quite frequently accompanied with small and minute 
hemorrhages. The headache frequently is introduced by vomit- 
ing, which sometimes occurs in paroxysms, with brief intervals. 
Occasionally it is combined with a disturbance of consciousness 
or of paralysis of some cranial nerve (see page 180). (2) Acute 
meningitis gives rise to an increased blood pressure, which, in 
turn, causes an outpouring of serous fluid into the meninges. This 
produces pressure on this membrane and on the terminal sensory 
nerve filaments. It may also cause headache by involving the 
nerve filaments and meningeal endings in the inflammatory 

Toxemic Headaches. — These are due to: (1) Exogenous 
poisons, as alcohol, lead, iron ether, nitroglycerin, amyl nitrite, or 
arsenic, and (2) endogenous poisons, as the toxins of pneumonia, 
typhoid fever, influenza, small-pox, chronic gastritis, chronic 
Bright' s disease, diabetes, cirrhosis of the liver, cerebral syphilis, 
gout, hyperthyroidism, starvation, and possibly diseases due to 
alimentary disturbances. Toxins act by altering the intracerebral 
pressure through their action on the vasomotors and possibly also 
directly upon the sensory filaments in the meninges. In addition 
to the reflex head pain, some slight sluggishness of intellect is gen- 


erallj associated with these conditions, and this may progress to 

Of the toxemias the starvation products due to nutritional 
defects, caused by anemia, are the most frequent cause of head 
pain. The head pain which they produce is mostly of local origin 
and has been ascribed to a lack of nutrition of the trigeminal 
nerves, or, according to Neuman, to a disturbance of the brain 
cortex. This disturbance leads to pain. This manner of pain pro- 
duction explains why the headache is relieved when the patient 
reclines, for, in doing so, he increases the blood supply to the 
brain and incidentally the nutrition. 

Anemia. — The diagnostic criteria associated with anemic 
headaches, which, in a way, are starvation headaches, are pain, 
generally vertical, and made easier on the patient reclining; pal- 
lor, especially marked on the lips ; disturbed sleep ; drowsiness ; 
edema of the ankles ; drooping of the eyelids ; and feeble carotid 
pulsation, a symptom which is of great diagnostic importance. 
Lenhartz (Munich Med. Woch., 1876, Nos. 8-9) showed that the 
headache and dizziness of chlorosis are associated with an in- 
crease in the subarachnoid pressure ; therefore, it is this increase 
in pressure and (in many cases) not the anemia which is the 
cause of the headache. 

Congestion. — Cerebral congestion seems to be a true cause of 
headache. Edinger claims that the headache of migraine is of this 
type, i. e., that it is due to a vasomotor congestion. For the expla- 
nation of the causes of these headaches, see under Vasomotor, 
Paralytic Headache, which is described under Headache of 
Chronic Origin. 

Cerebral congestion leads to an increase in the amount of fluid' 
in the brain. This increased amount may be the result of an 
increase in the amount of blood in the brain substance (edema), 
or in the quantity of the cerebrospinal fluid. The increase in the 
amount of blood in the brain is the result of an increase in the 
intracranial blood pressure, or of venous congestion. 

Increased arterial pressure in the cranium may or may not 
be associated with increased (systolic mean) arterial pressure. 


In some cases an increased arterial supply to the brain is due both 
to an increased heart action and to an interruption to the return 
flow through the venous channels. Some causes of increased intra- 
cranial blood pressure, which may, in certain conditions, incite 
head pain, are the following : stooping, lifting weights, sitting up 
suddenly, lying down quickly, the horizontal position, hard strain- 
ing at stool, physical exertion, running and extreme heat. 

Predisposing Factoids.— There arc certain factors which reflexly 
act upon the blood vessels or the vasomotor centers and cause such 
a lessening in control that slight causes, which otherwise would 
have no action, act upon the cerebral centers, and lead to a cerebral 
congestion. These factors are mental excitement, anger, or men- 
tal labor (severe), acting as a reflex cause of neurasthenia, which 
in turn acts principally as a predisposing factor in headache pro- 
duction. Other reflex and clinical factors are found in alcoholics, 
coffee and tea drinkers, and in those suffering from fevers. Sun- 
stroke and rapid chilling of the surface, as in colds, also have the 
same effect. In come cases there is a further lessened resistance 
to the above acting causes, because of a vasomotor ataxia due to 
nicotinism (Schmidt). In headache due to increased intracranial 
arterial pressure the pain generally is of a throbbing nature, 
the throbbing being due, perhaps, to a backward and forward flow 
of the cerebrospinal fluid. The pain is accompanied by a fulness 
of the head especially marked on coughing or on any sudden 
exertion. A flushed face, injected eye grounds, general irrita- 
bility, sensory disturbances and increased heart action also accom- 
pany this condition. There is also a form of arterial congestion 
due to a vasomotor paralysis in which pain is present in all parts 
of the head, but is especially severe on the top and in the temples, 
where it seems as though the head would burst. There is also a 
painful sense of pressure behind the eyes, which seem to bulge 
forward. Periods of freedom from pain intervene; then there 
are recurrences, often just before the menses, or when the atmos- 
phere is heavy. 

In headache due to general hyper hlood-tcnsion, Matthew 
(Quarterly Journal of Medicine, 1909, II, 261) found that a 


reduction of about 30 mm, Hg in the blood pressure was almost 
invariably followed by an alleviation of the head symptoms. 

Another cause of hypertension headache is the local increase in 
blood pressure, the result of inflammation, as in meningitis. Here 
the pain is generally associated with a slow, strong pulse, though 
no rise in the mean arterial pressure may be noted. In this it 
differs from aortic regurgitation, which also causes headache, but 
in which, although there is a sudden strong pulse (high systolic 
pressure), the mean arterial pressure is reduced. A third cause, 
the result of cerebral arteriosclerosis, is the elevation in the 
cerebral systolic pressure, which may be high, though the mean 
arterial pressure may be normal. 

Moleen writes : "Of the general symptoms of cerebral arterio- 
sclerosis, headache stands first. It is usually dull, not throbbing, 
and quite often is described as a feeling as though a tight band 
were compressing the head. It occurs most frequently in 
the morning after walking about, and diminishes as the day 
advances, except in syphilitic arteriosclerosis, in which it is 
usually most severe at night. Dizziness, or vertigo, as a symptom, 
is next in importance to pain. ISTumbness, tingling, twitching, 
weakness in a limb, or in one-half of the body, and disturbances 
in articulation are also common." 

Headache may be caused by increased venous pressure, as well 
as by increased arterial pressure ; or both may interact to produce 
increased intracranial pressure. Headaches of the first type are 
present when there is any obstruction to the return circulation, as 
in tricuspid regurgitation (which produces back pressure), 
thyroid enlargement (producing static back pressure), sinus 
thrombosis, and paroxysms of coughing. Tight neck bands and 
epilepsy (Knowlton) may also cause headache. 

General Consideration of Hypertension Headaches. — 
Hypertension headaches are very severe and usually are badly 
borne. It is most likely that in all hypertension headaches there 
is a supersensibility of the nerves supplying the dura, and thus 
more cognizance than normal is taken of changes in intracranial 
pressure. In these headaches the pain is eased by the patient draw- 


ing his head far backward and burying it in the bed clothes. If 
the neck-muscles are in a state of tonic contraction, we may pre- 
sume the lesion causing the condition to be of an inflammatory 
nature, probably one affecting the meninges. If this is the case, 
bending the head forward seems to increase the pain, and rotation 
is also painful, the pain being in the nape of the neck, and fre- 
quently on the side opposite to that toward which the rotation has 
taken place (Schmidt). Swallowing, as well as lying down, at 
times causes pain. The patient often attempts to fix the head 
with the hands, so that movement cannot take place. Hyperten- 
sion headaches are quickly relieved by the taking of a purgative. 
This would hardly happen if the headache were due to a toxemia, 
in which case the headache would last for some little time, un- 
til the toxic material could be removed. ]S[ow, it behooves us to 
ask, how a purgative so quickly relieves the headache. It is rea- 
soned by Schmidt that intestinal stasis causes meteorism, and that 
this in turn causes "stasis in the superior vena cava and in the 
cerebral veins through the restriction of the respiratory venous 
aspiration" ; and purgation causes a revulsion in this condition, 
and a normal respiratory circulatory activity. He also remarks 
"that the important part played by normal intestinal peristalsis in 
facilitating the venous circulation in the portal district must not 
be forgotten. The headache may be temporarily increased if the 
act of defecation is accompanied by considerable straining" 
(Schmidt, p. 43). A point of value in diagnosing increased ven- 
tricular pressure is that the pain of increased ventricular pressure 
is always referred^ — while that due to meningitis or tumor (menin- 
geal), etc., is always localized to the area involved. 

Associated with hypertension headaches are changes in the 
fundus of the eye, such as dilatation of the veins, hemorrhage into 
the retina, and choked disc, all of which are due to mechanical 
agents. There are also present mild inflammatory lesions, partly 
due to obstruction of the lymphatic return flow. 

Pressure points (see Neuralgia, Kg. 44) can often be dem- 
onstrated in the area of distribution of occipital-trigeminal nerves. 
Hiccoughs, vomiting, abnormalities in pulse and respiration, pes- 


sibly due to vagiis involvement, are also found. The spots seen 
dancing before the ejes are due to optic nerve involvement, while 
the buzzing in the ears is the result of involvement of the audi- 
tory nerve. 

Increased intracranial pressure is often evidenced by a visible 
distention of the veins of the brow or of the scalp. The degree 
of stasis may be fairly well judged by the magnitude of the dila- 
tation of the venules of the upper eyelid (Gushing). Where in- 
creased intracranial pressure is present, repeated examination of 
the urine should be made in order to detect, if possible, the 
presence of a nephritis. 

Among other associated symptoms of tension headaches are 
great debility, disinclination for any kind of work, anorexia, and 
distressing dreams with fright on awakening. Actual hallucina- 
tions are occasionally present; edema of the cortex of the skull 
sometimes occurs; red blotches at times cover the entire surface 
of the body, and the striae of the skin, which are produced by 
stroking with the finger, often persist much longer than the normal 
time. Thunderstorms aggravate or initiate the pain. Headaches 
of this variety should be diagnosed from those due to brain tumor 
by an eye examination. Choked disc is present in tension (tumor) 
headache, and is absent in vasomotor paralytic headache. 

Head pain may also be due to an actual, as well as a relative, 
increase of the cerehrospinal fluid. This increase may be local- 
ized to either the meninges or the ventricles. Increase in the men- 
ingeal fluid without an accompanying inflammation may be due 
to anemia (such as chlorosis or constipation with acetonemia). 
Increase in the ventricular fluid may be caused by an increased 
production of the fluid, or, if the production of the fluid is normal, ■ 
by a blocking of the foramina of exit (Foramen ]\Iagnus or the Ac- 
queduct of Sylvius), which causes an accumulation of fluid in 
the ventricles. Accumulation of fluid may occur in any of 
the cavities of the brain, from a blocking of their foramina of 
exit by new growths, inflammatory exudates, or foreign bodies. 
That a foreign body may cause such an obstruction is proven by 
the many reported cases in which the removal of an extraneous 


substance, such as a bullet from a position in the brain where 
it was producing obstruction, relieved the pressure and cured the 
headache. Angioneurotic hydrocephalus is also a cause of head 
pain which is due to an accumulation of the cerebrospinal fluid 
in the ventricles. Cerebral compression may also be the cause of 
an internal hydrocephalus, and thus cause head j)ain. Gushing, 
in speaking of cerebral compression the result of tumor growth, 
says that he succeeded in demonstrating, in the dog, that the 
longitudinal sinus may completely collapse at an early stage of 
compression with a venous stasis of high degree. If there is 
increased tension, from any source, a similar collapse may be pro- 
duced in the sinus rectus, with stasis in the vena galena, and this 
produces an internal hydrocephalus without direct implication of 
these vessels by pressure from a neighboring growth. This in- 
ternal hydrocephalus produces pressure and traction on the dura 
mater which results in head pain. 

Reflex causes of headache are the last to be considered, but 
they are not by any means the least important. Keflex headaches 
are due principally to organic disturbances of the uterus, ovary, 
eyes (iritis, glaucoma, chronic eye strain), sinus disease (nasal 
and frontal), hemorrhoids, decayed teeth, digestive disturbances, 
and toxic disturbances. The reflex headaches are due to irrita- 
tion of the nerve centers, and owe their presence to circulatory 
changes in the brain. 

Under reflex headaches it is also proper to consider headaches 
which follow intense irritation of the organs of special sense, for 
in many cases headaches follow a loud noise, exposure to an in- 
tense light, or a strong and disagreeable odor. These headaches 
are probably reflexes from the centers affected to the centers of 
the cutaneous area in which the pain is felt. 

Hunger headaches are due to a lack of nutrition in the brain 
cells of the cerebral cortex (in reality toxic headaches). This 
condition is common in children. 

Headaches which follow excessive venery are probably due 
to cerebral fatigue. To the same class belongs the headache 
which follows loss of sleep, such as occurs in those who have been 



up all night, or in those who have missed an accustomed mid- 
day nap. 

Disturbance of the brain substance from worry, etc., may 
cause some change in the molecular structure of the cortex, 
and this, in turn, produces reflex circulatory disturbances, 
which, may be the cause of pain. Associated symptoms of such a 
state, according to Drein, are malaise, irritability, digestive and 
visceral disturbances, nausea, confusion of ideas, and vertigo. 


Carious teeth 

Cerebral arteriosclerosis 

\ Ear disease 

' Parotiditis 

Pharj-ngeal disease 

Fonsil disease 

lonsOlar gland is at this point 

Maximum pain in angina 

Fig. 64. — Locations of the Principal Headaches. 

Xeuralgia of the cortex is also given as a cause of headache. 
As neuralgia means but an increased irritability of the sensory 
centers, or of the nerves conducting sensation and is used more 
to define a functional lesion, it may not be entirely jDroper to 
apply the term to the condition in which pain is produced by a 
cortical organic irritative lesion leading to lessened resistance 
and increased susceptibility. We find an increased suscepti- 
bility of this kind in neurasthenia and allied depressive states, 
in which a bright light, a thunderstorm, etc.. will produce 



headache. It is also held that there is a headache caused bj an 
irritation of the cerebral cortex by toxic materials, such as "was 
claimed bv the older writers (Boerhaave, Van Sweten) to occur 

('Referred pain from vertebra 
. Arthritis deformans 
I Meninges — meningitis 
J .Malignant disease (sarcoma) of 
> vertebra 

' Aneurysm of vertebral arterj' 
Elevation of the intracranial 

pressure, as in: 

(1) Hydrocephalus 

(2) Nephritis 

Fig. 65. — Figure Illustrating the Locations of the Principal Head- 

The back of the head and the nape of the neck are supphed by: 1. Occipitahs 
major, which hes toward the mid-hne and which is a branch of the 2d 
cervical nerve which passes through between the axis and atlas, and 
may be easily injured, owing to the great mobility of these parts; it is 
also affected in tuberculosis of this region; therefore pain would be felt 
in the occipitahs major area of distribution in disease of either the atlas 
or axis. 2. Occipitalis minor, which lies more laterally. 3. Auricularis 
magnus, which supplies the posterior surface of the ear. Occipital head- 
ache pain begins at the junction of the skull and the cranium and runs 
up the back of the head to the vortex or laterally to the back of the ears. 

in rheumatic headaphes. These headaches are of a mobile char- 
acter, and occur at various parts of the cranium, being especially 
common in the occipital and frontal regions. The pain seems to 
be well within the skull, and pressure on the surface does not 
modify its character as is the case in rheumatism of the scalp. 


The muscles of the neck are more or less rigid, and the movement 
of the head is painful. Conditions of cold and dampness influence 

Fig. 66. — Occipital Headache. 

the head symptoms the same as they influence rheumatic affec- 
tions of the joints. 

Fig. 67. — Frontotemporal Headache. 

In many painful lesions of the brain the skin over a cer- 
tain area of the head is very sensitive to pressure. This is 



thouglit to be due to the relations existing between the nerve 
filaments of the meninges and those of the scalp overlying the 
affected area. 

Diseases producing reflex headaches are : brain abscess, 
chronic appendicitis, gall stones, chronic gastritis, intestinal de- 
rangements, etc. The menstrual period also is often ushered in 
with a severe headache. 

In the accompanying drawings the locations of the principal 
headaches are given; and since these locations can be illustrated 
much better than described, the latter has been thought unnec- 
essary. (Figs. 61, G9j, 63, 64, 65.) 

Fig. 68. — Temporal Headache. 

In almost every case of headache the patient tries to ease the 
pain by making pressure on the head. This is illustrated in 
figures 66, 67, 68. 

Diagnosis of Headache. — The following may be of use in the 
diagnosis of headaches: 

Okigin. — First, ascertain if the headache is of recent or of 
remote origin. If it is of recent origin, examine for : 

(1) Acute infectious diseases in which the pain may be the 
result of a direct action on the pain-conducting trigeminal tract, 


or due to an elevation of tlie intracranial pressure. The most 
common infectious diseases causing head pain are influenza, ty- 
phoid fever, tonsillitis, and the acute exanthemata (measles and 
scarlet fever). 

(2) Injury (traumatism). 

(3) Toxemia: (a) endogenous (hepatic torpor) ; (b) exogen- 
ous (constipation, drugs). 

(4) Intracranial lesions (meningitis), either tuberculous or 
septic. In either case, the characteristics are a constant pain, in- 
terrupted by paroxysms of greater severity, and increased by 
movement or on the taking of food or drink. Vomiting and 
nausea occur in the absence of the ingestion of food. In some 
cases, when the intracranial pressure becomes high, optic neuritis 
follows. Tuberculous meningeal headaches, as a rule, are frontal 
or occipital (Taylor, 632). 

Probably the headaches of all the acute diseases are due to 
toxic causes. While headache is a common accompaniment of all 
acute infectious diseases, yet some, as pneumonia, may be entirely 
free of headache throughout their whole course. 

Remote Origin. — If the headache has been of a chronic type, 
a knowledge of the relative frequency of the different forms of 
chronic headache may aid greatly in forming a diagnosis. Accord- 
ing to Edinger, two-fifths of the chronic headaches are of the in- 
durative type, two-fifths are of the migraine type, and one-fifth 
consist of other types. The majority of all headaches are in the 
frontal region. In our examination of structural changes, as a 
cause for chronic headache, we begin an examination of the dif- 
ferent organs in the following order: 

(1) The eyes produce the so-called ocular headaches. In 
these headaches the pain is, as a rule, more severe on using 
the eyes. Brooks thinks that the principal eye conditions giv- 
ing rise to headaches are errors of refraetion, by which an 
excessive amount of work is thrown upon the ciliary muscles; 
want of balance between the external muscles of the globe; and 
retinal hyperesthesia, in which the retina is very sensitive to light. 
Ocular headaches are usually located over the middle of the eye- 


brow and the pain radiates into the back of the eye (Jessop, 

(2) The nose ^ causes a pain that lies to the inner side of, 
and extends higher on the forehead than the pain due to eye strain. 
The nasal conditions causing headache are stenosis (chronic ob- 
struction due to foreign bodies, rhinoliths, tumors, hypertrophy of 
the turbinate, bending of the septum), vasomotor alterations, epi- 
staxis, sinus involvement. lodid coryza should also be thought of, 
especially in those who are undergoing treatment for syphilis. 
The cause of the headaches in cases of nasal obstruction seems 
partly at least to be due to the lack of oxygen, because it has fre- 
quently been found that patients suffering from recurring head- 
aches, or from neurasthenia, are immediately relieved of the 
trouble by the removal of some obstruction in the nose or sinuses. 
Turbinate headache is usually periodic, depending on the inter- 
mittent swelling of the mucous membrane covering the surface of 
the anterior end of the turbinate. Sinus involvement may 
cause severe pain; for in one of Hartman's cases trigeminal neu- 
ralgia, due to this condition, had persisted for weeks, the pain 
being so intense that sleep had been impossible. The most 
diverse treatment had given no relief. All pain vanished im- 
mediately after the maxillary sinus was evacuated of the cheesy 
matter with which it had been filled. In other cases supraorbital 
neuralgia, which recurred every day at a certain hour, was the 
result of inflammation in the frontal sinus, and was cured by 
appropriate treatment. The pain may be due to the inflamma- 
tion itself, to compression from secretions, or merely to rare- 
faction of the air in the sinus. The trouble may not be due to 
an inflammatory process, but merely to the occlusion of the sinus, 
by which communication with the air is shut off. This is a com- 
paratively frequent occurrence, and is liable to cause distressing 
pain. Opening a communication into the nose banishes the pain 
at once (Hartman). A particular variety, met most frequently 
by Thompson (488), and associated with old fractures of the 
nasal bones, seemed to begin at the roof of the nose and to pass 

* See page 342, Nasal Stenosis. 


horizontally backward to the occiput. It was always aggravated 
by prolonged bending forward of the head, as in writing, and 
had a special tendency to cause incapacity for mental work. 

(3) Diseases in the accessory nasal sinuses are also causes 
for headaches. The sinuses affected are the frontal, antral, eth- 
moidal and sphenoidal. Headache due to disease of these sinuses 
is generally relieved by the discharge of pus or mucus from 
the nose. In these conditions, the seat of pain is generally frontal, 
although most authors believe that it bears no special relation 
to the site of the disease. Lack (623), however, holds that the head- 
ache due to sphenoidal sinus involvement is "referred to the back 
of the head and then radiates down the back of the neck." That 
due to the ethmoid is found in the frontal region, in the eyes, and 
deep in the head behind the eyes; while that due to the antrum 
is found over the molar bone and may extend upward to the 
temporal region. He also states that the frontal sinus headache is 
most severe at the "top of the head over the posterior part of the 
frontal bone." The original location of the pain is generally 
continued throughout the disease. 

(4) The ears, in many cases, cause head pain. The prin- 
cipal causes acting upon the ears to produce head pain are anemia 
and mastoid disease. 

(5) The alimentary tract gives rise to headache. Various 
forms of mouth disease, gastrointestinal disorders, intestinal para- 
sites, constipation, dyspepsia, and cholelithiasis may be the cause 
of severe pain in the head. Dull, generalized headache and coated 
tongue are due to indigestion. 

(6) In kidney lesions the pain is felt particularly at the 
back of the head, and radiates down the neck. Torticollis and 
disease of the vertebrae should be eliminated. 

(Y) Brain tumors and abscesses are common causes of 
headache. The location of the pain often corresponds with the 
site of the tumor. Sometimes the pain is increased by pressure. 
It may not be constant, but generally it is periodic. Cerebellar 
tumors commonly are on the side opposite to that in which the 
headache is found. Tumor headaches are caused by the pressure 


of the growth obstructing the vena magna galeni or the aqiiednct 
of Sylvius (Schmidt), both conditions lead to increased intra- 
ventricular pressure. The location of a brain tumor cannot be 
diagnosed from the situation of the headache. For a fuller con- 
sideration of these headaches, see page 182. 

(8) Psychical strain will produce severe headache. This is 
'likely to be frontal, and generally is the result of long-continued 

worry or severe mental effort. A .headache of this character is 
influenced most by psychic states. Mental effort greatly in- 
creases it. In this it differs from a headache due to increased 
intracranial pressure, which is most influenced by mechanical 
factors, such as change in position of the head and body, bleeding 
from the nose, or blood-letting. 

(9) Between lead poisoning and gout, and the uric acid 
diathesis, probably there is a close relationship. All these pro- 
duce headache. 

(10) The headache of anemia is due to a hydremic hydro- 
cephalus, with a consequent rise in the intracranial blood pressure. 
Elevating the head often causes great relief. 

(11) Cerebral arteritis: Of the general symptoms of cere- 
bral arteriosclerosis, headache stands first. It is usually dull, not 
throbbing, and quite often is described as a feeling as though a 
tight band were compressing the head. It occurs most frequently 
in the morning, after walking about, and diminishes as the day 
advances, except in syphilis, in which it is usually most severe 
at night. A peculiarity worth noting in this class of patients is 
that, even though arteriosclerosis is present, there is also a lowered 
blood pressure, which is probably the result of secondary cardiac 
weakness. It averages from 110 to 130 mm. Hg. The causa- 
tion of the headache can be explained from the fact that, since 
the cerebral arteries are terminal arteries, a sclerosis of the coats 
would cause a narrowing of the lumen, which would produce an 
anemia of the cortex of the brain. The anemia, of course, would 
then produce headache and giddiness. Why there should be a 
systemic lowered blood pressure, is difficult to explain. 

The patient should also be questioned in regard to the con- 


stancj of the headache ; that is, whether it is intermittent or per- 
sistent, and then, if it is intermittent, whether the intermittence 
is regular (periodic) or irregular. 

Inteemittent Headaches (Periodic Type). — According to 
Edinger, two-fifths of all headaches from which patients suffer are 
of the periodic type. The most important, as well as the best 
known, of the periodic headaches is migraine. Two types of 
migraine are recognized: 

(1) The reflex migraine, which begins later in life than 
does the true variety, and is dependent principally upon a non- 
inherited, peripheral cause. In this class of cases there is no evi- 
dence of a neurosis in the family, and the headache becomes 
worse instead of better in middle life. A preliminary visual 
spectrum is absent. The headaches are warded off by purgatives 
and laxatives, while, in contrast, the true migraine headaches are 
not influenced by such means, but are lessened by phenacetin. 
The principal causes of reflex migraine are eye strain, constipa- 
tion, and intestinal toxemia. These headaches may also be pro- 
duced by peripheral factors, as injury to the nerve following a 
blow on the head, or a fall, in which the third nerve has been 
damaged. In some cases, after recovery from a head injury, a 
patch of meningeal thickening may remain and cause head pain. 
In this form there is sometimes a recurrent third nerve paralysis, 
and the patient is attacked by severe headache lasting a day or 
two. The third nerve recovers its functions in the course of some 
weeks. A visual spectrum rarely develops. 

(2) In the hereditary form of migraine there is a distinct 
history of the heredity. Generally some member of the family 
has been a sufferer from this condition. If none has been affected 
with headaches often there is one member who is subject to attacks 
of epilepsy, neuralgia, etc. Migraine appears in adult life and 
may be caused by prolonged debilitating diseases. An individual 
attack is frequently induced by the menses, which it may precede 
or follow, a prolonged railway journey, a close, badly ventilated 
room, great heat, emotion (as anger), excitement, the use of a 
small quantity of alcohol or tobacco, unusually early awakening, 


omission of a meal, or strain of the eyes, especially if the strain is 
on the ciliary muscles. 

Migraine gives rise to a throbbing pain. It begins with dis- 
comfort and gradually increases until it is agonizing in its 
severity. It generally begins over one eye and then spreads to 
the forehead and the side of the head. It is increased by bending 
over, by noises, or by any sudden exertion. Eating may also in- 
crease it. Drinking alcoholic beverages and smoking make it 
worse. Strong light augments the distress. Because of all these, 
the patient generally seeks a quiet and dark room and lies very 

A symptom almost pathognomonic of migraine is scintillating 
scotoma, which appears before the pain commences. The scotomata 
appear as floating dark spots in the visual field, the borders of 
which are often serrated and illuminated. Some see only the 
illuminated edges of the spots, and may complain of dulness of 

The individual paroxysm of pain may last for a few minutes, 
or an hour, while the period of attack may last for a few hours or 
all day. The premonitory symptoms of migrane are lassitude, 
irritability and incapacity for arduous work. They often appear 
in the evening before the attack, while on the morning of the 
attack the patient complains of numbness in the head and an ex- 
tremely tired feeling. The pain begins gradually, and is felt 
deep in the head, with a sensation as though the head were split- 
ting. There are also a burning and a sense of pressure in and 
behind the eyes. The pain, as a rule, is unilateral. It is asso- 
ciated with a feeling of distress. Loss of appetite and cold feet 
are often present. The physical signs associated with migraine 
are: a generally pale face (though it may be red), injected con- 
junctivae, narrowed palpebral fissure and contracted pupils. The 
contraction of the pupils is an important differential sign, as in 
all other conditions where severe pain is present the pupils are 
dilated. Vomiting, as a rule, finally occurs, and when it does the 
headache ceases. 

True migraine is the most important and commonest of the 


forms of periodic headache. The severe pain in the head seems 
to be due to an increase of the intracranial pressure. The hemian- 
opsia, the dimness of vision, the numbness in the tongue, cheek or 
arm, and the temporary aphasia are all suggestive of sudden ar- 
terial constriction in the cortex.^ Vomiting is also a most char- 
acteristic sign of elevation of intracranial pressure. 

Brunton is also in accord with the arterial constrictive hypoth- 
esis, for he claims that the pain of migi'aine is due to a con- 
traction of the peripheral part of the temporal artery, and a dila- 
tation of the j)roximal part. He noticed that in every case of 
migraine the carotid was widely dilated, while in many cases the 
peripheral part of the temporal artery seemed to be contracted, 
and in other cases dilated; but, in every case, the little branch 
which turns upward on the forehead was found to be firmly con- 
tracted. Pressure upon the carotid would oftentimes relieve the 
pain, which ceased as long as the pressure was maintained, but 
returned as soon as the pressure was removed. Pressure upon the 
carotid artery of necessity produces pressure upon the pneumo- 
gastric nerve, causing gTeat disturbance to the respiration, with a 
"feeling as though the entire chest were contracted, or as though 
someone were pressing down with a giant's weight upon it." 
Therefore, pressure on the artery, because of these symptoms, 
cannot be long continued. 

These views of Brunton are in accord with the opinions of 
Edinger and Harris, who also think that migraine is accompanied 
and conditioned by a contraction of the peripheral arteries. While 
as yet no vasoconstrictor nerves can be found in the brain, the 
pale eyegrounds, the general vascular spasm which causes dizzi- 
ness, and also the occasional disturbances of speech all seem to 
confirm the anemic hypothesis. Another idea of the cause is ex- 
pressed by Jelliffe, who follows Spitzner in believing that migraine 
is due to an absolute or relative stenosis of the foramen of Monroe. 
According to the same authority, an occasional hyperemia of the 

1 Although cerebral arterial constriction has been given by many 
authors as a cause of increased intracranial pressure, it seems to me that 
the arterial constriction does not cause a congestion but an anemia, and that 
fhe primary condition is not an arterial constriction but a dilatation. 


brain leads to a hyperemia of the choroid plexus. This, in turn, 
causes a greater narrowing of the foramen, and an increase of 
tension in one or both ventricles. This causes a still further con- 
gestion of both choroid plexuses, and increases the narrowing. 
The vicious circle continues until the pressure is relieved or the 
tension is reduced by a shock reaction, such as occurs in vomiting, 
or in the use of the vasodilators. 

According to Levi and Rothschild, there is also a migraine 
due to a diminished secretion of thyroidin. These doctors have 
succeeded in ameliorating seven cases of migraine with thyroidin ; 
and in their description of thyroid migraine they say that ''the 
existence of this affection is evident by the migraine being re- 
lieved with thyroidin ; by the hypothyroid signs we meet in people 
suffering from migraine ; by the autotherapy of pregnancy ; by the 
influence of female sexual life (puberty) on the appearance of 
the affection; by the paroxysmal crises (during menstruation) of 
the affection ; and by their cessation at the menopause. Thyroid 
migraine symptoms do not differ from those of common migraine. 
It is either precocious or tardy, hereditary or acquired ; unilateral 
or bilateral; syndromic or symptomatic. It may last only some 
hours or days, but is always paroxysmic." 

Other causes of periodic headaches are, malaria, syphilis, 
habit, hysteria, lymphatism. 

If the periodic headache is due to malaria, there is some 
malarial history. Chills, fevers and sweats occur, an enlarged 
spleen can be palpated, and plasmodia can be found in the blood. 

In headache due to syphilis, the pain, as a rule, occurs at 
night, and is usual after excitement. 

Hahit Headache. — If a periodic headache occurs at the same 
time of the day or week, examine for some disease or habit, in 
the history of the patient, which would be likely to bring on 
headache, or to act as a predisposing factor in its production. 
Inquire into the manner of work, sleeping, eating, etc., of the 

Hysterical headache may be present, in which case there are 
other signs of the hysterical involvement. 


Ross speaks of a form of headache which he calls the lymphatic 
headache. He describes it as having the following characteristics : 

(1) It is present, and most severe, on walking, and tends to 
lessen in intensity, or altogether disappear, in from one to six 

(2) It usually manifests itself as a dull, heavy ache, or as 
a frontal or temporal throbbing. Less frequently it is occipital, 
vertical, or unilateral. Infrequently, also, it is neuralgic. 

(3) In its typical form it is exceedingly chronic, often of 
several years' duration, and most intractable. It is the common, 
occasional headache to which most people are subject. 

(4) It is associated with a deficient coagulability of the 

The postures assumed by patients suffering from the different 
varieties of headaches are illustrated in Figs. 66, 67 and 68. 
In all of these headaches, the principal factor sought by the patient 
seems to be the application of pressure over the painful area. 
This, in nearly all cases, relieves the pain; so it is possible that 
in these headaches the pain is a superficial pressure phenomenon 
(skin, muscles, etc., of scalp), and that pressure applied over the 
area of local pain removes the congestion and thus relieves the 

Hyperalgesic zones of the head, according to Hannsa (62b), 
frequently occur in lesions at the base of the skull. The most 
common of these are the result of bullet wounds of the skull, 
basilar fractures, and concussion. The zones may lie in the area 
of distribution of the second to fifth cervical segments — or in the 
distribution area of the trigeminus. Hannsa, as well as Wilms, 
Milner, Yorschiitz, Clairmont, etc., claim that the cause of these 
zones is a lesion of the sympathetic. 

In this connection, also, Head has observed that most of the 
viscera cause pain which is referred both to an area in the body 
and, in many cases, also, to one in the head, where it is expressed 
as tenderness. Head found that these areas were associated with 
certain visceral areas of tenderness. These associations are given 
by Head in the table on page 295 (Head, Brain, 1894, p. 464). 

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part of nose 

b. Caries of teeth 


Disease of last two molars of 
upper jaw 

Superior laryngeal 

a. Disease of wisdom teeth of 

lower jaw 

b. Disease of posterior part 

of dorsum of tongue 


Diseases of the ear 

Sternomastoid area 

Diseases of the chest, asii 
berculosis of the limg, a 

Fig. 70. — Lateral View of Head's Zones. 
Solid black areas show points of maximum tenderness. 




It seems that "all the thoracic and abdominal viscera, which 
refer pain into the dorsal areas of the scalp, are supplied by 
what might be termed the vago-glosso-pharjngeal nerv'e — this con- 
sisting of the vagus and the glosso-pharjngeal nerves. These two 

Vertical -! -^'^^^^^ '^^ posterior portion of the 
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the eye 


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dorsum of 

b. Referred 
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b. Disease of 

c. Disease of 

Diseases of 
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b. Disease of 
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Superior laryngeal 

a. Disease of 
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Fig. 71. — Lateral View of Head's Zones. 
(From Head.) 
nerves represent the visceral branches of a set of nerves whose 
somatic sensory roots are to be found in the sensory portion of 
the fifth nerve. Therefore, it is possible to understand how the 
impulses passing up the vagus may be referred to the distribution 
area of the fifth nerve. 


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Area on Body 

Associated Area on 

Organs in Particular Relation 
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1 Liver. 
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Cervical 4. 



Dorsal 2. 


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\ Heart (ventricles). 

[Ascending arch of aorta. 

Dorsal 3. 


r Lung. 

\ Heart (ventricles). 

[ Arch of aorta. 

Dorsal 4. 



Dorsal 5. 



\ Heart (occasionally). 

Dorsal 6. 


f Lower lobes of lungs. 
\ Heart (auricles). 

Dorsal 7. 


C Bases of lungs. 
] Heart (auricles), 
[stomach (cardiac). 

Dorsal 8. 


r Stomach. 

\ Liver. 

[Upper part of small intestine. 

Dorsal 9. 


f Stomach (pyloric end). 

\ Upper part of small intestine. 

Dorsal 10. 


[ Liver 
1 Intestine. 
1 Ovaries. 
[ Testes. 

Dorsal 11. 


r Intestine. 

1 Fallopian tubes. 

1 Uterus. 

[ Bladder (contraction). 

Dorsal 12. 


f Intestine (colon). 
\ Uterus. 




This includes all pains from the base of the skull to the coccyx. 
They may be the result of a lesion of the structural units of 
the back (skin, muscles, nerves, or bone), or may be referred 
from other regions. The skin of the back is hypersensitive in 
many of the diseases of the internal organs — in these the zones of 
Head are, as a rule, pronounced — and in all cases should be 
sought. In many of the infectious diseases the skin is also very 
sensitive, both to touch and to pricking. 

In examining the back for the presence of pain phenomena first 
try light touch and pin-point pressure. If these are not painful, 
make deep pressure, or grasp the muscles between the fingers; 
should the patient now complain of pain, we may conclude that it 
is the muscles which are affected. The muscles most frequently 
affected are in the neck, and the most common affection is rheuma- 
tism, which in the neck produces torticollis, and in the small of 
the back lumbago. These rheumatic affections are characterized by 
a sudden onset, the great pressure sensibility over definite muscular 
areas, the increase of the pain on movement, and the favorable 
influence through massage, faradization and heat. In many cases, 
also, the pain and tenderness seem to be influenced by the weather, 
becoming much worse on rainy days. Only by their course do 
the chronic rheumatisms of the back muscles differentiate them- 
selves from acute forms. Johnson (Brit. Med. Jour., 1881, 
p. 221) mentions back pains, which lasted a long time, and which 
appeared on bending forward. They were double-sided, and only 
unilateral if the vertebrae were held crooked. These pains were 
worse after their onset, and diminished after a little movement.- 
I have observed a similar case in a colleague. In this instance, 
however, not the muscular but the tendinous structure was dis- 
eased. The colleague complained of back pain, which would ap- 
pear at certain parts of the vertebral column, upon motion or 
fixation; for instance, it would appear if he stepped from the 
pavement incautiously, and upon strong pressure. Examination 
showed, in this otherwise healthy individual, a high degree of 



sensibility of the vertebral spines of the two lower thoracic verte- 
brae. Especially sensitive were the connecting fascial ligaments. 
The overlying skin was also sensitive. Deformity was not pres- 
ent, and sudden pressure over the vertebrae was not especially 
painful. There was, therefore, no reason to think of a destruc- 
tive process in the bodies of the vertebrae. I learned that the col- 
league had worked with a microscope, in a somewhat uncomfort- 
able position, several hours daily for many weeks, the microscope 
being placed so low that he had to work with his back very much 
bent. After working with the instrument in a better position, the 
pain disappeared in a short time without further therapy. 

Since lumbago is so frequently confused with that of neuras- 
thenia the following table of diagnostic difference is appended. 



Pain located. 

In the region of the lower 
lumbar vertebra and 
spreads out sideward. 

In the sacral region and 
spreads upward. 

Method of onset. 


Very gradual. 

Influence of motion. 

Increases pain. 

No action on the pain. 

Points of tenderness. 

Pressure on increases the 
pain or also produces it. 

No pressure points. 

Psychical influence. 

Mental states have no in- 

Is influenced greatly by men- 
tal states, irritation (psy- 
chical) increases the pain, 
diversion reduces the pain. 

Vertebral column. 

Often some change or de- 
formity present, such as 
scoliosis; this can be dif- 
ferentiated from other 
forms of scoliosis by hav- 
ing the patient lie on the 
affected side, in a sharp 
angle, when the scoliosis 

No change or deformity. 

Myalgia, due to toxemia, is nicely illustrated in those infec- 
tious diseases in which backache is one of the most prominent 
symptoms. In small-pox the pain in the back is so severe that the 
patient, in many cases, is in the greatest distress. The nature of 
this pain, however, does not long remain in doubt, for the presence 



of the eruption soon clarifies the situation. In the so-called break - 
bone fever, of the Southern States, it is also most severe. Among 
the other infectious diseases in which backache is a prominent 
symptom are relapsing fever, influenza, tonsillitis, typhoid fever 
and diphtheria. — + 

Carious op\ne--5!^*- 
"Fracture Spinei'^ 
■PendalouLS Abd^S^*' 

Disease Q/^ -Xij^^ 
Pelvic Or^Sng^k 

DlSecx&e ^^ 

Big. 73. — Figure Showing the Modifications of Pain in the Lumbar 

Region by Change of Position. 
The arrows indicate the direction of movement and + indicates increase 

of pain, while — indicates decrease of pain in the diseases mentioned 

when the motion is made as indicated. 

In myalgia from sprain some history of injury is usually 
obtainable, and in some cases evidences of traumatism are present. ■ 
In myalgia due to fatigue the pain is more of an aching character. 
Sitting upright or standing increases the pain. Ease may be 
obtained, as a rule, by reclining. This condition is frequently 
associated with neurasthenia, anemia and depressed mental or 
physical states. Such a fatigued state is frequently experienced 
by dentists, mechanics, barbers, surgeons, or comes on after cer- 
tain forms of exercise, such as rowing. Pain may also be due to 


inflammation in the subcutaneous tissues, as in perinephritic ab- 
scess and inflammation of the retroperitoneal glands. 

In the neck, the sternomastoid muscle, either as a result of 
changes in its substance (result of toxic irritations), or as a re- 
flex from other adjacent structures (neck glands, Ludwig's angina, 
vertebral, or local lesions), or from neurotic influences (either 
congenital or acquired, acute, or chronic), becomes so sensitive 
that it remains in a state either of tonic or clonic contractions. 
When the contractions are chronic they abate gradually but 
quickly reappear on the least irritation or attempt at movement. 
This condition is termed torticollis. For a fuller description of 
this the reader is referred to special works on the subject. 

After a consideration of the muscles as causative factors of 
the back pain the vertebra and joints should next be considered. 

Vertehral diseases, as tuberculous caries (when inflammation 
is acute), cause pain, elicited either by sharp spinal shocks made 
by forcibly pushing the head downward, or by having the patient 
stand with feet together and then, after elevating himself on his 
toes, bring the heels down to the ground with considerable force. 
When vertebral disease is present, pain will usually be felt in 
the diseased area. Involvement of the third to the fifth vertebra 
generally gives rise to more pain on bending forward or back- 
ward than does involvement of other vertebrae, because it is at this 
level that flexion and extension of the spine most frequently occur 
(Cooper, 807). 

Leukemia with vertebral myeloma may also give rise to back 
pain, likewise, also, the vertebral metastatic growths, especially 
prostatic, mammary, or adrenal tumors. 

The sacrovertebral joints are also a frequent cause of back 
pain, which may be either the result of inflammation, or of dislo- 
cation. If of inflammation the same signs and symptoms of in- 
flammations are found as in other inflamed joints (see page 239). 

Dislocations also display here the same signs as when they 
occur elsewhere. Here, however, should be mentioned the sacro- 
iliac dislocation, the pain of which causes it frc(iuently to be mis- 
taken for lumbago and sciatica. However, in this condition the 


pain is in the sacroiliac region, and extends do\vn to and over the 
anus. There is also rigidity of the retrospinal muscles. 

For the elucidation of this lesiqn Goldthwaite (800) has for- 
mulated two tests (an anterior and posterior one), which are 
known by his name. He describes them as follows (Annals Surg., 
Vol. LI, 1^0. 3, p. 420) : 

"For the anterior test, place the patient on a bed with, say, 
the right limb fixed on the bed ; then the left leg is lifted from the 
bed without flexing the knee. If it does not go as high, if the 
extension or flexion of the limb, when the limb is extended, is not 
equal to that on the other side, and if the pain is acute, we suspect 
an anterior displacement of the sacrum. The posterior test can be 
made by extending the limb upward, with the patient lying on the 
face." The diagnosis between muscular and ligamentous pain of 
the spine (Cooper, 802) is that passive posturing will cause pain 
if the ligaments are involved, while if the muscles are involved, 
active posturing will cause pain. 

Reynolds and Lovett (805) also speak of cases in which, owing 
to an abnormal stooping-forward position, the center of gravity 
is moved forward, and, as a consequence, considerable strain is 
thrown upon the ligaments and back muscles, with the consequent 
production of pain. 

Osteomalacia is also productive of very severe back pain, but 
the associated pregnancy and the typical pelvic and sacral de- 
formity render its diagnosis easy. 

Pain over the coccyx (the so-called coccydynia) may be due 
to injury of the coccyx from a fall, or from over-distention of 
the inferior pelvic outlet during childbirth. It is also found in 
hemorrhoids, anal fissure, and proctitis. Lesions of the conus 
medullaris also may cause pain referred to this region. 

Referred pain may be felt in the back and be present, either 
as a result of disease of the viscera, or of some more distant organ 
or region. The viscera lesions, most of which commonly give 
rise to pain in the back, are : the lungs, stomach, intestine, liver, 
and gall-bladder, kidney, pancreas, spleen, and pelvic organs. 

Lungs. — Affections of the lungs, if they extend to the pleura, 


frequently lead to pains which are felt in the back, especially as 
the patients localize the pains in the upper part, in the intra- 
scapular space and in the shoulder, if the area of disease is local- 
ized in the apex or in the upper lobe. The more frequent cause 
for such a condition may be a beginning tuberculosis. Pressure 
sensibility of the skin and musculature, in the above-mentioned 
region, is not often present. Increase of the pain in breathing, 
and especially in coughing, gives an indication, and an exact 
examination of the lungs makes the cause clear. 

Heart and Aorta. • — Just as frequent causes for back pains are 
affections of the heart or of the aorta. Here the pain occurs not 
only in the back, but also may be found as radiating pain in the 
arm, esj^ecially in the left arm and in the left shoulder. A fre- 
quent complaint of such patients is a sensation of constriction of 
the thorax, as though it were being pressed in a vise ; but in this 
case the hand of the corresponding part of the back, or the shoul- 
der and the left arm, are oversensitive. It will not be hard to 
differentiate these varieties of pain from those which are caused 
by disease of the spinal cord or of the dura. The circumstances 
that heart pains almost always occur in paroxysms, and that these 
attacks, in the first place, are called forth through bodily exer- 
tion, psychical irritation, etc., indicate their origin in the heart. 
An exact examination discovers changes in the aorta and the car- 
diac muscle. Absence of signs of a spinal cord disease completes 
the finding. 

Stomach. — With the referred pains of gastrointestinal visceral 
disease are associated the hypersensibility of the skin and muscu- 
lature of the painful region, and of the corresponding part of the 
vertebral column, on the left side, in particular. But these pains, 
as they are especially observed in ulcer of the stomach and in 
pyloric stenosis, are not very difficult to connect with the stomach, 
since their appearance and variations in intensity depend chiefly 
upon the taking of nourishment, and especially upon the quality 
of the food. It is unnecessary to say that the further examina- 
tion of the stomach, in such a case, must yield signs of disease of 
that organ. In many cases of total stenosis and cramp of the 


esophagus, a severe paiii is frequently felt in the shoulder region, 
and a girdle sensation is exj)erienced in the thorax. 

Intestines. — Pelvic pains are frequently due to diseased proc- 
esses in the intestine. Gas collections in the large intestine pro- 
duce pain in the pelvis and in the flanks, the cause of which 
reveals itself upon the application of a purgative. Intestinal 
ulcers do not so frequently cause pelvic pain. On the contrary, 
pelvic pains in carcinoma are an important diagnostic phenomenon. 
Very frequently they are associated with a radiation in the limb 
and in the perineum, especially if the carcinoma is situated in a 
deeper part of the colon. Yet, here the pains almost never appear 
without accompanying symptoms. Very frequently they are asso- 
ciated with intestinal symptoms, so that their recognition causes 
no difllculty. Only an inflated colon can, as a single pathological 
entity, produce dull pain in the back, usually on a level with the 
kidneys. But here an exact anamnesis, with the fact that the onset 
of the pain depends upon the passage of feces or of gas, makes the 
diagnosis clear. 

Liver and Gall-bladder. — One observes, very frequently, in 
liver and gall-bladder troubles, pains in the shoulder, in the arm, 
and in the back — almost always on the right side. There is often, 
also, an excessive sensibility of the skin and of the correspond- 
ing musculature. This can be demonstrated upon picking up 
folds of the skin and pressing upon certain places (the region near 
the tenth to the twelfth vertebral spine). When the remaining 
signs of gall-bladder and liver disease are found, the diagnosis is 

Kidney.- — The spontaneous and pressure sensibility in diseases 
of the kidney (inflammation, embolism, congestion, tuberculosis, 
neoplasm) is situated in the flanks and pelvic region. Frequently, 
also, hyperesthesia of the skin is found. Here chemical and 
microscopical examination of the urine make an important dif- 
ferentiation. In connection with pus inflammation (perinephritic 
abscess) pain occurs in the lumbar region, which is increased by 
touch and pressure, as well as by coughing, sneezing and motion. 
In a similar manner, the pain of nephritis manifests itself. Radi- 


ation occurs in the thigh or is present in the form of an intercostal 
neuralgia. Patients with kidney stones complain of trouble and 
pressure in the lumbar region. If the pain is intense, and takes 
the form of colic, it radiates downward, as a rule (thigh, testicle, 
ovary). Frequently, however, it is found in the lumbar region 
and in the loins. The direction of this radiation, and the circum- 
stance that the lumbar pain is increased, if one makes a journey 
over a rough road, would lead one to think of a kidney stone, 
further signs of which are disclosed ui)on examination. 

Pancreas, Spleen, etc. — Of the pains of many pancreatic af- 
fections, it is likewise known that they radiate in the back, or (in 
girdle form) towards the front. Frequently diseases of the 
female genitalia lead to severe pelvic pain, and finally the spleen, 
also, under some conditions, produces pain which radiates into 
the pelvis, the left shoulder, the left shoulder blade, and the inter- 
scapular region. Spleen tumors, especially, produce pain, and 
their presence will be thought of as an associated condition by 
the presence of the above described pain. 

The pelvic organs (uterus and ovary) are probably the most 
frequent causes of backache in women. The principal lesions are 
a malsituated uterus (retroversion, retroflexion, or the binding of 
it down to the pelvic floor by adhesions, in which the pain is 
worse just before the menstrual period) ; and inflammation of the 
uterosacral ligaments (Garrigues, 803). Tender spots on either 
side of the second sacral vertebra are due (Garrigues) to cellulitis 
of the uterosacral ligaments. Pressure over the inflamed utero- 
sacral ligaments produces pain at these places. The pain is worse 
on exertion, especially in sweeping. Sexual intercourse is pain- 
ful, as a rule. Examination will disclose the abnormal and pain- 
ful ligaments. Pregnancy and menstruation are also potent causes 
for backache ; but in these conditions there is generally present 
some previous disturbance of the lumbar structures which pre- 
dispose them so that the addition of congestion or traction, result- 
ing from pregnancy or menstruation, produces pain. In some 
cases, during pregnancy, an actual relaxation of the sacroiliac 
ligament is present (Andrews and Hoke, 806). 


Inflammations of the uterus may also cause backache. (For 
a fuller consideration, see "Pain in the Female Genitalia/' Chap- 
ter XXXIL) 

The genitourinary organs in the male (prostate, seminal 
vesicles) cause lumbar pain. The urinary bladder, also, when 
diseased, frequently giyes rise to pain in this region. 

Back pain may also be caused by static foot errors, hysteria, 
anemia and chlorosis. 

In static foot errors the pain is relieved on the patient lying 
down, or on the correction of the errors of position. 

"In hysteria the backache is usually referred to the lumbar and 
sacral regions. It often extends upward over the dorsal area and 
downward over the gluteal muscles" (Clara F. Dercum, 150). 

Anemia and Chlorosis. — The anemic and chlorotic individual 
very frequently complains of back pain. It occurs as rheumatic, 
pain, which is most severe in the morning, after arising, and im- 
proves during the forenoon, if the patient moves about. 

The lesions of the spinal cord causing back pain have been 
previously considered, and will not be dwelt upon here. 


After the consideration of back pains, it is next in order to 
discuss the pains which usually are present in the limbs. The 
upper limbs are probably not so frequently subjected to pain sen- 
sation as are the lower limbs ; and when they are, the causative 
factor is more likely to be of a circulatory nature. The principal 
pain areas are in the joints, which are frequently affected by 
rheumatism. The shoulder joint, in particular, is subject to 
gonococcus infection. Over the shoulder are also found the re- 
flected pains from the liver on the right side, and from the spleen, 
pancreas and stomach on the left side. On both sides pains re- 
flected from the diaphragTQ, extrauterine pregnancy and pleura 
are found. In the shoulder also is present the pain resulting 
from inflammation of the deltoid bursa, which lies between the 
humerus and the acromion process of the scapula. A characteris- 


tic of this pain is, that it is caused by elevating the shoulder, and 
is very severe until the arm becomes horizontal, when the pain dis- 
appears. The pain is localized immediately below the acromion 
process, between this j^rocess and the head of the humerus. Ten- 
derness is also most marked at this point. 

Generalized pains are usually neuralgic in origin (for which 
the reader is referred to the section under Brachial ISTeuralgia) . 

The LOWEK EXTREMITIES are greatly affected by circulatory 
changes. A slight indication of the type the symptoms may as- 
sume is given by the so-called sleeping pains which follow upon 
the partial stopping of the circulation in a limb. Generalized 
pain of a paroxysmal character, more pronounced on the external 
and posterior surfaces than on the internal surface of the limb, 
is likely to be due to a sciatica (a complete description of which 
is given in a separate section). When the pain is on the anterior 
surface of the thigh, and runs down and to the inner side, it is 
probably due to involvement of the anterior crural nerve. Should 
neuralgia be present the pain is paroxysmal and is of great in- 
tensity. If it is a referred pain from pressure on the nerve from 
tumors or bowel accumulations (William Bruce, 502), it is more 
of a steady, constant, dull ache. 

In the lower limbs, the joints, especially the hip joints, are 
very prone to tuberculous infection. The hip, when so affected, 
at first causes a pain on the inner side of and somewhat posterior 
to the knee; so that, in many cases, disease of the knee joint is 
falsely diagnosed. Rheumatism is also common in these joints, 
and frequently pain and swelling in the knee follow upon the 
locking of the joint by a so-called rice body. The pain is due to 
a stretching of the ligaments. It may be only a pinching pain, or 
it may be excruciating, if the cartilages are caught (Barker). 

Flat-foot^ also, is a potent cause of pain in the region of the 
knee. The pain is on the inner side of the patella and may radi- 
ate up and down the front of the leg. The j)ain is much in- 
creased on active exercise of the foot, especially by running or 
walking. Pain in the legs which is not influenced by position, 
pressure, heat or cold is often the forerunner of brain hemor- 


rhage. When it occurs in persons of advanced years, with hard 
arteries, it should be looked upon with suspicion (Musser). 

At times the heel is very painful (pododynia) — so much so 
that the patient is unable to walk. This pain may be due to local 
conditions (exostoses on the surface of the os calcis). Those on the 
posterior and inferior surfaces are the most frequent (Thorndike, 
"Orthopedic Surgery," p. 164) ; there may also exist spurs run- 
ning out from the under side of the os calcis ; bursitis of the bursa 
under the os calcis ; or an associated flat-floot may be present 
(Keen's "System of Surgery," Vol. II, p. 56). Painful swelling- 
may also be present on the posterior surface of the heel at the 
insertion of the tendon-achilles into the os calcis. The patient 
walks with the feet everted, while the use of the calf-muscles is 
painful. Pain in the heel may also be caused by lesions which 
are at a distance, as from urethral stricture (Luxmoor, Brodie, 
Thompson, Van Buren, Keyes, and Gouley), vesicle calculus, cys- 
ticoprostatitis, inflammation of the neck of the bladder, cystalgia, 
or neuralgia of the neck of the bladder, which, in some cases, may 
be mistaken for bladder stone (Yon Pitha, 272), renal calculus, 
gonorrhea (Fournier, 274), and locomotor ataxia (Segun and Buz- 
zard). It is also present in pregnancy. Pain on the sole of the 
foot may be caused by exostoses on the internal cuneiform or the 
base of the first metatarsal, or at the junction of the scaphoid and 
cuneiform (Thorndike). 

A peculiar and painful affection of the foot, occurring only 
in adults, and most frequently in women, is termed metatarsalgia 
(Morton's disease). 

"Typical cases of this affection have sudden cramp-like pains 
starting in the third or fourth metatarsophalangeal articulation 
and radiating to the tips of the toes and up the leg. The sudden 
onset may be brought on by a misstep, or by the fatigue of stand- 
ing a long time, and occurs almost invariably when the shoes are 
worn. In some attacks are infrequent ; in others they practically 
disable the patient and are provoked by inappreciable causes. The 
pain is so great that the patient removes the shoe, rubs and com- 
presses the front of the foot, flexes and extends the toes, and, after 


a time, the pain ceases, leaving no sign, or only a very slight sore- 
ness over the articulation on deep pressure. The cramp-like pain 
may be referred to a single or to several adjoining joints or to all 
the bones of the metatarsal articulation. It is due to a pinching 
of the i^lantar nerve between the bones, or to an abnormal strain 
on the ligaments connecting the heads of the metatarsal lx)nes" 

Tenderness is found on pressure over the heads of one or more 
metatarsal bones, or on lateral pressure in the region of the meta- 
tarsophalangeal joint (Forbes, Montreal Med. Journ., April, 


If a pain is of a peculiar, dragging nature, increased on breath- 
ing, and especially when deep inspiration or complete expiration 
is performed, and if it runs round the chest from the ensiform 
cartilage in a slightly downward direction to the tenth rib pos- 
terior, it is generally the result of diaphragmatic traction. It oc- 
curs in great cardiac and respiratory activity, dilatation of the 
stomach, severe tympany, coughing, sneezing, or hiccoughing. A 
pain slightly lower, and restricted to the area of the liver, may be 
caused by hepatitis (see Liver). On the left side, over the 
area of the spleen, a perisplenitis similarly will cause a pain. 

Pain localized immediately in the middle of the abdomen, be- 
tween the ensiform and the umbilicus, may be due to pancreatitis, 
ulcer of the stomach, gall-stones, cardiac lesions (tricuspid regur- 
gitation), liver and adnexal diseases, epigastric hernia, and duo- 
denal ulcer. If the pain is located around the umbilicus, the 
causative lesion may be a hernia of the linea alba, volvulus, em- 
bolus of the superior mesenteric artery, meteorism, tympany, in- 
testinal obstruction, swollen mesenteric glands, early stage of 
appendicitis,' ileocolitis and intestinal strangulation. 

Pain downward and slightly to the right is very severe in 
appendicitis, oophoritis and salpingitis. Pain on the left side is 
severe in salpingitis and oophoritis. On either side pain running 
from the back around to the anterior surface of the abdomen, and 

Diaphragmatic trac- 
tion, as in great 
cardiac and respir- 
atory activity 

Dilatation of stom- 

Coughing, sneezing, 


Ovaries and tubes 

Appendix and tubes 

Broad ligament 

Femoral hernia 
Inguinal and femor- 
al adenitis 

Pain radiating down 

to foot 
Crural neuralgia 
Disease of femur 
Femoral hernia 
Abdominal tumors 
pressing on crural 
Uterine or ova- 
rian tumors 
abscess (psoas) 


Stretching of liga- 


Premonitory of apo- 

Spurs on OS calcis 
Bursitis under os 

Associated flat-foot 



Fig. 74. — Pain Areas in Trunk and Lower 

Cancer of breast 
Uterine disease 

Splenic disease 



Ulcer of stomach or 


Cardiac lesions (tri- 
cuspid regurg.) 

Liver involvement 


Hernia of linea alba 


Embolus, sup. mes. 



Intestinal colic 

Intestinal obstruc- 

Intestinal strangula- 
tion (hernia) 

Swollen mesenteric 

Referred pain in hip 

joint disease 
Obturator hernia 

Tender point in flat- 


Pain in flat-foot 




Disease of ovary 

Morton's disease 


Pain above the um- 
Lesions of small 
Embolus sup.mes. 

Arterioscl er osis 

sup. ma. 
Pancreas disease 
Liver, gall-bladder 
or duct disease 
Stomach disease 

Pain below umbili- 
Colonic disease 

Colonic impac- 
Rectal disease 

Embolus inf. mes. 

Breast di.seases 
Uterine disease 





Ileum disease 
Pain over entire ab- 


Rheumatism or 
neuralgia of the 
abdominal wall 

Intestinal perfor- 


Pneumonia (chil- 

Aneurysm (abd. 

Fig. 75 — Pain Areas in Breast and 

. 309 


then down to the testicle or labia generally indicates a renal or 
ureteral disorder. 

Pain below the umbilicus in the mid-line is found in colonic 
disease, rectal disease, embolus of the inferior mesenteric artery, 
uterine disease, or disease of the urinary bladder. 

Pain over the entire abdomen results from disease of the 
abdominal wall (myalgia, neuralgia, rheumatism, peritonitis), in- 
testinal perforation, tympanites, enteroptosis, referred pain in 
pneumonia (in children), and aneurysm. For a more complete 
discussion of abdominal pain, see Chapter XIX. 

Pains due to tabes are very frequent in the abdomen. 


Pain over the chest in the sternal region may be caused by 
diseased bone, mediastinal inflammation, changes in the medias- 
tinal glands, aortic aneurysm, bronchitis and stomach disorders. 
Over various areas in the chest are the pains from pneumonia 
and pleurisy. Radiating around the chest wall and paroxysmal 
in type are the pains of intercostal neuralgia and vertebral and 
cord diseases. Pain, localized to the pectorals and made worse on 
raising and lowering the arm results from rheumatism of the 
pectoral muscle. It can also be the result of invasion of the 
pectorals in cancer of the breast. 

Pain on the left side, over the cardiac region, indicates a 
possible lesion of the heart, and this is confirmed, if it is found that 
the pain runs down the ulnar side of the arm; even as far as the 
little finger. Pain in the breast is frequently present during 
menstruation, in pregnancy, and in uterine and ovarian diseases. 
It may, also, be the result of a local inflammation, in which case 
the entire breast is markedly tender and signs of inflammation are 


Pain in the clavicular region is frequently associated with 
new growths (pleura, clavicle), aneurysm of the subclavian, and 
pulmonary tuberculosis. In the supraclavicular region it may be 


Sterno mastoid 
disease (wry- 


Liver disease 
Extrauterine preg- 
nancy (in fe- 
• male) 



Disease of bone 



Mediastinal inflam- 
Mediastinal glands 


Aneurysm of aorta 






Circumflex neural- 

Pectoral neuralgia 


Axillary gland in- 

Intercostal neural- 
Necrosis rib 


Girdle pain-tabes 
Diap hragmat io 
traction in 
coughing, sneez- 
ing and hic- 


Hepatic congestion 
Referred pain 



Vertebral diseases 

Subphrenic abscess 

Gall bladder disease 
Pancreatic disease 
Gall duct disease 

Renal colic 
Ureteral colic 

Ear disease 


Ludwig's angina 
Inflammation o f 
base of tongue 
or submaxillary 


Fig. 76.— Pain Areas in Neck, Chest, 
Clavicular Region and Abdomen. 





New growths, glan- 
dular, etc. 

Aneurysm, subclav- 

Pulmonary tuber- 

Deltoid bursitis 

Lung disease 
Pectoral neuralgia 

Cardiac disease (an- 
gina pectoris) 

Pancreatic disease 

Stomach disease 
Uterine and ovar- 
ian pregnancy (in 

Stomach lesions 



Gastric disease 
Pancreatic disease 

26 and 27 


Swollen and in- 
flamed inguinal 

Inguinal hernia 



due (on the right side) to liver disease, or (on the left side) 
to disease of the colon or stomach (in new growth of which also 
search for metastatic glands in this region). In extrauterine preg- 
nancy with rupture, pain, when present, is on the same side as 
the rupture; in colonic disease and diaphragmatic pleurisy, pain, 
as a rule, is on the diseased side. Pain over the shoulder is present 
in deltoid bursitis and also, in a wider area, in neuralgia of the 


When a patient complains of pain in the neck, the first idea 
suggested to the physician is that he is suffering from some in- 
flammatory disease of the upper respiratory passages. This idea 
is increased almost to a certainty if, with the j)ain, there is also 
present an inspiratory stridor. It may be a sign of larjTigitis, 
thyroiditis, or tracheitis. Should pain be felt only on turning 
the neck to one side or the other, and should one of the sterno- 
mastoids be in a state of tonic contraction, sternocleidoid disease 
or wry-neck is indicated (see Fig. 69). This tendency to lateral 
flexion and rotation is also seen at times in brachial neuralgia. 
Pain above the sternomastoid and below the inferior maxillary is 
found in tonsillitis, inflammation of the inferior maxillary gland, 
or in inflammation of the floor of the mouth, the so-called Ludwig's 
angina. Pain over the os hyoides or larynx is a sign of inflamma- 
tion of the bone. In some cases an inferior maxillary neuralgia 
may be present. Pain just anterior to the ear, on the side of the 
face, indicates ear disease, parotitis, or diseased teeth (inferior 


Pain in the back, over the entire vertebral column, indicates 
neurasthenia, traumatic spine or mediastinal disease ; in the area 
between the scapula it indicates pericarditis, lung disease, dia- 



phragmatic pleurisy and aortic lesions ; over the scapula, lung in- 
volvement or pleurisy is indicated. 

On the left side, between the vertebrae and the scapula, pain 


Lung disease 

Splenic involve- 

Aortic aneur- 
ysm (gnawing 





Vertebral dis- 

T. b. c. tu- 
mors, frac- 
Cord (crush, 


Sacroiliac dis- 


Liver, gall blad- 

Headache, back 
of head, 
pain radi- 
ating down 
the back 
from brain 

lung disease 


Aortic lesions 

Vertebral and 

Liver disease 

Lungs: pneu- 
monia, pleu- 
ral disease 

Rib disease 

Intercostal neu- 


Tabes, local- 
ized menin- 

Liver (perihep- 




Kidneys (peri- 

Colon impacted 


Disease of coc- 


Anal fissure 


is present in aortic lesions and stomach disorders; at the apex of 
the scapula, on the left side, splenic disease is indicated ; and, at 
about the same level on the right side (in many cases a little 
lower), liver disease is indicated. Pain generalized over the back 
of the chest may be due to myalgia, lung or pleural disease. Pain 
radiating around the side of the chest is due to intercostal neu- 
ralgia. By reference to Fig. Y8, the local points of tenderness in 
brachial neuralgia and in the so-called diaphrag-matic neuralgia 



are slioTvn, as well as tlie points of tenderness in intercostal neu- 
ralgia and in angina pectoris. 

Pain in pulmonary \ 

Dots indicate points 
of tenderness in 
intercostal neu- 

General tenderness 
over all the verte- 
bree in neuras- 

Subacromial bursi- 

Trousseau's points 
of tenderness in 

Plane of emergence 
of the dorsal 


Subjective pain 
Hypertension head- 

Spine of the 7th 
cer\'ical vertebra 

Painful points in 
angina pectoris 

Trousseau's point 
of local tender- 
ness for brachial 

Tender points over 
the 2nd and 3rd 
dorsal spine in 
brachial neuralgia 

Spinous processes 
all tender in neu- 
rasthenic spine 

fPressure causes pain 

1. Spinal caries 

2. Aneurj'sm 

3. Spinal menin- 


4. Tuberculosis 

r Uterine disease 
Kidney disease 

-^ Lumbago 

Acute infectious dis' 
L eases 

Fig. 78. — P.un Aheas in Spinal Column. 

Lower down in the back, in the neighborhood of the lower rihs, 
are found the areas which are painful in perihepatitis and dia- 
phragmatic disease, while a little lower is found the area in which 
pain is located in kidney disease. Lower still, and in the neigh- 
borhood of the sacrum, are the areas where pain is present in colon 
involvement, retroperitoneal gland, and uterine disease. In the 
entire small of the back are found the occupation-pain, uterine- 



disease pain, perinephritic-abscess pain, lumbago, and lumbar- 
abscess (tubercular) pain. In the same area, but extending over 
the sacroiliac articulation, is the pain of sacroiliac disease. Over 
the coccyx and adjacent regions is located the pain due to disease 

Area of re- 
ferred pain in 
liver disease 

Aortic aneur- 

3 and 4 
Tender points 
often present 
in gastric ad- 

Renal disease 
Perirenal ab- 
Lumbar abscess 

pain running 
along verte- 
bral coliunn 

Tuberculous ca- 



Fig. 79. — Pain Areas in Back. 


Area of tender- 
ness in gastric 


Uterine disease 
Occupation tire 
Clerks, etc. 



Sacroiliac dis- 


Sacroiliac dis- 

Coccyx injuries 

and disease 
Rectal disease 
Cervical disease 

Broad ligaments 
Ovaries (Butler) 

of the coccyx, rectal disease, and cervix disease. Pain over the 
buttocks, and running down the outer surface of the limb, is 
especially frequent in ovarian and broad ligament disorders. 

Pain in the inguinal region may be due to inguinal or femoral 
adenitis, and if it radiates down toward the foot it may be due to 
phlebitis, crural neuralgia, disease of the femur, femoral hernia, 
abdominal tumors pressing on the crural nerve (aneurysm, uterine 
or ovarian tumors, tuberculous abscess-of the psoas). 

Pain in a joint may result from rheumatism, tuberculosis, 
acute synovitis, stretching of ligaments, or floating bodies. 



When sensitive and sensory impressions falling upon the 
retina exceed a certain maximum in intensity they become dis- 
agreeable. If their intensity reaches a still higher degree the 
sensation provoked is painful. Just what are the threshold values 
for various forms of stimuli of the retina are not all determined. 
Thus, the action of very strong light on the eye causes a painful 
sensation, with blinding. Such sensations scarcely ever arise 
spontaneously. They are nearly always the result of the action 
of adequate stimuli which have been increased above the normal 
limits. These disagreeable sensations are to be distinguished from 
others due to irritation of the nerves of common sensation. In 
the descriptions to follow the latter will be simply called pain. 

Under normal conditions an individual is not ordinarily con- 
scious of the normal retinal stimuli, and if the existence of this 
organ intrudes itself upon consciousness this is usually a sign of 
a pathological condition. This consciousness is usually brought 
about through the medium of pain. As we do' not possess any 
objective method for measuring pain, we must rely upon the 
information given by the suffering individual, which must be 
checked up by our own experience. Self -training, self-control, 
physical and psychical distraction are circumstances which con- 
siderably influence the intensity of this pain perception, increas- 
ing, diminishing, or even abolishing it completely. 

The same uncertainty which exists in the estimation of the 
intensity of the pain dominates the characterization of the quali- 

1 By Decent Hans Lauber, M. D,, and Olaf Buttin, M. D., assistants of 
the Eye Clinic, Vienna. 



ties of pains. In the same disease the same pain will not he 
described in the same way by several j)atients, and will be differ- 
ently described by the same patient at different times. The pain 
may be described as blunt, dull, boring, burning, pulling, throb- 
bing or tearing, but, unfortunately, there is no possibility of ascer- 
taining whether the similar terms used by different patients 
describe similar sensations. 

As far as the duration of pain is concerned, we are in a far 
better situation. We can more easily believe the correctness of 
statements which describe pain as continuous, periodical, inter- 
mittent, or periodically exacerbating. Under certain circum- 
stances these characterizations can be of great diagnostic value. 


In examining the different factors that can cause or increase 
pain in the eye, or its surroundings, we find that they may be 
touch, pressure, atmospherical influences, temperature, light, and 
tiring of the eyes by work. 

The topography of the eye and its adnexa points to the rami- 
fication of the first and second branches of the fifth nerve as the 
source of the tactile and consequently also of painful sensations. 
The third branch is of but secondary importance. All the other 
nerves can be excluded from further consideration. As a conse- 
quence of the very extensive ramification of the fifth nerve, it is 
found that irritation of different branches of the nerve may pro- 
duce a sensation of pain, or even other symptoms, in the ocular 
region. It is imjDortant to emphasize, at the very beginning, that 
irritation of any branch of the trigeminus may provoke a sensa- 
tion of pain in its whole distribution, and, further still, reflex pain 
can be elicited in all those nerves that are in close anatomical or 
physiological relation to the irritated nerve — for instance, the in- 
timate association of lachrymation to irritation of the trigeminus. 
Mechanical influences, acting upon the cornea, elicit lachrymation, 
just as easily as can the irritation of a tiny nerve stem in the pulp 
cavity of a tooth, or the irritation of the nasal mucous membrane, 


whicli are likewise innervated by the fifth nerve. Irritation of 
the bulbar terminal branches of the fifth nerve is generally accom- 
panied by hyperemia, -which extends from the immediate sur- 
roundings of the irritated place to the neighboring parts, and can 
lead to visible hyperemia of the conjunctiva. The numerous anas- 
tomoses of the fifth nerve with the seventh and the sympathetic 
explain the frequent refiex phenomena, such as sneezing, swallow- 
ing, jDupillary dilatation, vasomotor and secretory disturbances. 
All these reflexes can occur in association with pain in the realm 
of the fifth nerve. 

From a practical standpoint, pain is very important in a 
double sense, first, as a symptom of partial disturbance, which is 
often vague and allows many different explanations ; second, as 
the patient's prominent subjective complaint, by the removal of 
which the physician can gain much credit. 


The exact localization of pains in the eye region may be of 
symptomatic significance, yet here we encounter many uncertain- 
ties. In a case of iritis, for instance, we firmly believe that the 
pain originates in the ramification of the fifth nerve in the iris 
itself, and yet many patients do not complain of pain in the eye, 
but in the bone surrounding the orbit. The pain in glaucoma 
has its source in the globe; nevertheless, many patients complain 
only of headache or hemicrania until the tenderness of the globe on 
pressure convinces them that the eyeball is the affected organ. 
itTotwithstanding the fact that the localization of the pain may 
lead to false judgments, the following pages will attempt a diag- 
nostic analysis of pain, based upon its localization. 

The Eyelids. — The skin of the eyelids and their surroundings 
may be a source of intense pain in cases of inflammation. This 
pain may be spontaneous, and is generally very intense when the 
inflamed skin is touched. This kind of pain which is localized in 
the skin occurs in eczema, febrile herpes, herpes zoster, cases of 
phlegmon and abscesses of this region. In many cases the pain is 


associated with swelling of tlie tissues, so that the real focus of 
the disease can be found on palpation. In marked inflammatory 
edema of the lids one finds on touch an increased resistance of 
the tissue, which is considerably increased in some places. If the 
region of the internal canthus ligaments be the seat of tenderness 
to palliation the possibility of a beginning dacryocystitis or peri- 
ostitis should be thought of. Pain and resistance at the margin 
of an eyelid suggest a hordeolum; superficial pain of the skin, 
accompanying movable resistance, points to the diagnosis of a 
furuncle or an abscess, whereas an immobile resistance is an argu- 
ment in favor of periostitis. It should be remembered that inflam- 
mation or cicatrices in the region of the external canthus lead to 
marked edema of the eyelids, so that the localization of the painful 
spot and the accompanying resistance alone permits a diagnosis. 
Tumors of these regions, which are exceedingly painful, are occa- 
sional. N^euroma or neurofibroma are to be expected. Under cer- 
tain circumstances ulcerated carcinomata occur. They are in- 
tensely painful to touch. 

The pain in herpes zoster has a special character. It, at times, 
begins a few days before the appearance of an eruption; that is, 
during a period when the patient complains of general malaise. 
It is frequently impossible to explain such attacks of pain cor- 
rectly until the appearance of the eruption shows the nature of 
the disease. The pain in herpes zoster may persist with the same 
intensity for weeks and months after the skin lesions are healed 
and the accompanying keratitis and iritis have subsided. iN'ightly 
exacerbations of the pain are not rare. The pain frequently irra- 
diates into other branches of the trigeminus not apparently af- 
fected by the herpes. Simultaneously with the appearance of the 
intense pain there arises a hypo- or even anesthesia of the skin and 
superficial parts of the eye, so that the characteristic symptom 
complex of anesthesia dolorosa may appear. The sensibility re- 
turns slowly. Hyperesthesia is rare. ,These cases of herpes zoster 
represent the projection of a central lesion onto the peripheral 
endings of the nerves. Investigations of Barensprung, Head and 
Campbell, and Lauber have proved that the primary process is 


localized in the Gasserian ganglion. The skin, conjunctival and 
corneal changes are probably to be regarded as trophic lesions. In 
some cases (Eisenlohr) a peripheral neuritis has been found, so 
that not only lesions of the ganglion, but also those of the nerve 
are to be considered in herpes of this region. 

From these statements it can be seen that the pain in herpes 
zoster is a true neuralgic pain, as it is caused by a lesion of the 
ganglion or of the peripheral portion of the nerve. It is of the 
character of acute inflammatory neuritis, caused by some toxic 
agent. It is a pathological process, occurring in the sensory gan- 
glia, analogous to that in the motor ganglion cells in acute anterior 
poliomyelitis or polioencephalomyelitis. In addition to the virus, 
the nature of which is as yet unknown, other causes of herpes zoster 
exist. Such are traumatism, tumors, disease within the cavernous 
sinus, aneurysms of the ophthalmic artery, pulsating exophthalmos, 
poisoning by carbon dioxid and arsenic. All of these affect the 
fifth nerve, and are of etiological importance. 

A disease which resembles herpes zoster in some ways is neu- 
ralgic herpes of the cornea (herpes cornas neuralgicus of Schmidt- 
Rimpler). This is a periodically appearing affection, often re- 
curring at the same hour of the day. The attack begins by pain 
in the supraorbital branch of the fifth nerve, and is characterized 
by an eruption of small vesicles in the distribution area of this 
branch. The whole attack passes off in a short time. 

The pain which accompanies a febrile herpes of the cornea 
is due solely to the epithelial lesions, and does not show the typical 
neuralgic character of the two affections previously considered. 

Several other forms of neuralgia of the same region are to be 
distinguished from typical trigeminal neuralgia, which is a 
persistent and very torturing disease. They show the same symp- 
toms, but are secondary affections of the trigeminus. Acute neu- 
ralgias are caused by inflammatory conditions, such as orbital 
periostitis, empyema of the accessory sinuses of the nose, etc., 
and occasionally show relapses. Chronic neuralgias are due to 
tumor, keloids, or to chronic forms of periostitis and empyema, 
l^euralgia of the fifth nerve can also be caused reflexly by lesions 


in distant regions, as by caries of the teeth or in nasal affections. 
These can mislead the patient, as well as the physician. It is con- 
sequently necessary, in cases of neuralgic pain of the fifth nerve, 
to examine the entire distribution area of this nerve for causation 
lesions before making a diagnosis of idiopathic or primary (essen- 
tial) neuralgia. 

A diagnosis of neuralgia is generally based upon the tenderness 
of the nerve-stem to pressure. In the investigation of a case of 
neuralgia, pressure should be applied to the nerve exits ; i.e., over 
the supraorbital foramen, the infraorbital, and mental foramina. 
This excessive tenderness, accompanied by spontaneous periodi- 
cally exacerbating pain, is very characteristic. Tenderness to pres- 
sure is absent only exceptionally in neuralgia. This symptom 
alone, however, is not sufficient to make a diagTiosis of neuralgia, 
as in hysteria, also, the branches of the fifth nerve are frequently 
tender to pressure. Furthermore, tenderness to pressure may be 
a symptom of a general polyneuritis and not of an isolated affec- 
tion of the trigeminus. Especial attention should be called to the 
fact that neuralgic-like pains of the trigeminus may be sympto- 
matic of glaucoma, or they may be precursors of this disease, 
appearing a long time before the glaucoma can be recogTiized. 

Another type of periodically returning pain in the trigeminus, 
though generally affecting only its meningeal branches, is hemi- 
crania, or migraine. Here the so-called scintillating scotomata, 
with their characteristic features, are diagnostic. The attack be- 
gins with eye symptoms, and, during this period, the patient no- 
tices the scotomata with their luminous and generally moving 
margins. These attacks are then followed, as a rule, by intense 
unilateral headache, with frequent radiation of pain throughout 
the entire fifth nerve area. The cause of the phenomena is prob- 
ably a vasomotor disturbance, which, acting upon the meninges, is 
felt in the peripheral branches of the nerve. 

A very rare affection, likewise characterized by intense hemi- 
crania, is a recurring third nerve palsy — ophthalmoplegic mi- 
graine. Intense hemicrania introduces the attack, to which ptosis 
and almost total immobility of the eye, nausea, or vomiting are 


added. Such attacks persist for from a half a day to two days" 
or more, and may recur at irregular intervals of a few weeks or 
months. During the intervals of the attack the third nerve 
paralysis recedes, but may not completely disappear. 

Surroundings of the Eye. — Tender pressure points, so charac- 
teristic of neuralgia, may exist in other affections of the surround- 
ings of the eye. The cause of indefinite pain in the head, espe- 
cially of dull pain in the forehead, can occasionally be found by 
careful palpation, which reveals the nerve tenderness at a certain 
place. Tenderness of the bone to percussion and tenderness in 
the region of the trochlea are found in many cases of acute or 
chronic affections of the frontal sinuses and the anterior ethmoid 
cells. Thus, one may be guided to a correct diagnosis. Such 
cases can be differentiated by the existence of delimited sensitive 
areas from those other cases where the bone is sensitive through- 
out to pressure or percussion, and at the same time is diffusely 
thickened. These latter symptoms lead to the diagnosis of perios- 
titis and osteoperiostitis. Indolent thickenings of the bone are 
but rarely due to inflammation (lues, tuberculosis), and, as 
a rule, represent tumor or protrusion of the bones by meningo- or 

Conjunctiva and Cornea. — Pain in the conjunctiva and its cor- 
neal continuation is of the greatest interest to the oculist. The 
abundant end ramifications of the nerve plexus of the super- 
ficial layers of the cornea penetrate as far as the basal cells of 
the epithelium and explain the great sensitiveness of this organ, 
as well as the great intensity of the pain in superficial lesions 
(erosions) of it. The conjunctiva is much richer in nerves than 
other mucous membranes of the body. Inflammatory or traumatic 
irritation of the nerve endings in the conjunctiva gives rise to 
very severe pain, alike torturing to the patient and difficult for 
the physician to abate. Great sensitiveness to thermic, atmos- 
pheric, and light influences is present, and exposure to these in- 
creases the pain to the highest intensity. While there is not the 
least doubt, so far as thermic and atmospheric stimuli are con- 
cerned, that the nerve terminations in the conjunctiva and cornea 


can transmit pain stimuli and canse snch reflex disturbances as 
lachrymation and blepharospasm, yet light can also give rise to 
painful stimuli, and it is not so easy to determine how it acts and 
causes pain in corneal and conjunctival lesions. 

It is a fact, however, that in corneal erosions or in other super- 
ficial lesions of the cornea, likewise in iritis, there exists a great 
sensibility to light (photophobia), even when the patients keep 
their eyes closed, thus excluding atmospheric and thermic in- 

In iritis, whether primary or secondary to keratitis, one is 
inclined to attribute the pain caused by light to reflex contractions 
of the sphincter, and to the irritation (on pupillary dilatation or 
contraction) of the sensory nerves in the stroma of the iris. But 
if the iris is normal, and its contractility is suppressed by means 
of a mydriatic, it can no more be considered as a source of pain, 
and other causes of the corneal irritation to light (photophobia) 
must be sought. Wilbrand explains photophobia as follows: 
"Exposure to light leads to the formation of products of 
metabolism in the pigment of the retina ; if the forma- 
tion of such products becomes increased, they may cause pain in 
the ciliary nerves of the choroid, which contain filaments of the 
.fifth nerve. If those nerves are in a condition of pathological irri- 
tation, even small quantities of these products of katabolism can 
cause considerable pain. This theory, however, does not explain 
why the instillation of cocain into the conjunctival sac, in quanti- 
ties which can act only upon the superficial endings of the nerves, 
can in many cases quite suppress the photophobia. This would be 
in favor of an explanation which attributes light sensibility to the 
endings of the trigeminus in the cornea and conjunctiva, analogous 
to the direct action of light upon the iris. This theory is, how- 
ever, not satisfactory. 

Hyperemia of the conjunctiva, infiltration of both conjunctiva 
and cornea, detachment of the corneal epithelium in the form of 
vesicles and blebs surely lead to mechanical and possibly also to 
toxic irritation of the nerve endings. This explains why the 
pain is so very severe in conjunctivitis and superficial keratitis. 


Superficial traumata, wliich expose the superficial and subepithe- 
lial nervous plexi, are exceedingly painful. Deeper wounds, 
which penetrate the substance of the cornea and sever the nerve- 
stem, are less painful. 

In an irritative condition of the cornea and conjunctiva, 
tear-secretions retained in the conjunctival sac can cause consider- 
able complaint. The accumulation of tears in the conjunctival 
sac, when an eye is kept under a bandage after an operation, may 
cause great discomfort, and even pain, which can be instantane- 
ously relieved by removing the bandage and opening the eye. 
Small quantities of mucus or muco-pus, on the surface of the eye, 
are perhaps the cause of the sensation of a foreign body in con- 

In cases of gonorrheal or diphtheritic conjunctivitis the edema 
of both conjunctiva and lids may lead to such stretching of the lid 
that it can be the source of pain. However, this is easily re- 
moved by simple canthotomy. 

After foreign bodies of the cornea or conjunctiva have been 
removed the sensation of their presence frequently persists for a 
few hours and disappears, together with the subsidence of hyper- 
emia and the reparation of the tissue lesions. Observations of 
this kind prove that both hyperemia and the pressure of an almost 
imperceptible exudate are able to irritate the nerve termination to 
a high degree and cause pain. 

In erosions of the cornea the pain often has a recurring char- 
acter. According to von Reuss, two types of this affection can be 
distinguished. In the first slight pain appears on first opening 
the lids after sleep, or after they have been kept closed for a long 
time. This soon ceases. In the second type, after a period of 
apparent health, attacks of pain occur, having the same char- 
acter and intensity as those following the original trauma. They 
are caused by a plainly visible loss of epithelium in the same place 
where the primary injury had originally led to the loss of sub- 
stance. Both types of the affection are the consequences of an 
abnormal condition of the epithelium established by the trauma. 
Close examination of the cornea with a lens, or by the ophthalmo- 


scope, show minute opacities in the epithelium. In the first group 
of cases the corneal epithelium, which during the night is in close 
contact with the tarsal conjunctival epithelium, sticks fast to the 
latter and is torn off when the eye is opened. In the second group 
of cases (the recurring erosion in a strict sense) the epithelium 
degenerates, is cast off, and exposes the nerve plexus lying in 
the superficial layers of the cornea. 

The pain associated with corneal herpes and punctate superfi- 
cial dendritic and stellate keratitis is due to similar causes. Cor- 
neal ulcers of various types all expose the nerve plexus of the 
cornea, and can, therefore, cause more or less pain. The pain 
becomes more intense when the exposed nerves are irritated by 
the moving lids. Eor that reason a bandage is applied to prevent 
the movement of the lids, and thus to diminish the pain. It 
cannot relieve it completely, as the infiltration of the tissues exer- 
cises pressure upon the nerves and stretches them. Toxins pro- 
duced by bacteria also cause painful irritation of the corneal 
nerves. Sudden pain arising in a case of ulcerating keratitis 
frequently indicates perforation of the ulcer. The chief cause 
of pain in perforation of the cornea is the mechanical irritation 
of the iris. If the iris prolapses and cicatrizes, sudden and in- 
tense pain may again arise. This is a symptom of secondary 
glaucoma. The severe pain which frequently accompanies deep 
keratitis is largely due to a concomitant iritis. 

Referred pain is also present if the ulcer extends into the 
deeper layers of the cornea. The area of reference is in the fronto- 
nasal area, and also to some extent in the midorbital (Head). This 
referred pain is probably due to a deepening of the anterior cham- 
ber. Should a true cyclitis be present, the joain is referred fur- 
ther to the side in the forehead than in corneal ulceration, the 
midtemporal area being, as a rule, concomitantly involved with 
the midorbital. 

The Iris and Ciliary Body. — The'existence of a dense nervous 
plexus in the iris and the ciliary body fully explains the severe 
pain found in diseases of these parts. The specific etiology of 
iritis and iridocyclitis is also a factor in the origin of iritic and 


cyclitic pain. Its importance, however, should not be exagger- 
ated. The pain is frequently continuous, and may be localized in 
the eyeball itself, or in the surrounding bones, even in the entire 
half of the head corresponding to the affected eye. As in many 
other diseases, so in iritis and iridocyclitis exacerbation of the pain 
is observed toward the end of the night or in the early morning. 
This is not only characteristic of syphilitic affections, but occurs 
in the same way in rheumatic and traumatic cases of iritis. In 
rheumatic iritis, more often than in those due to other causes, 
severe pain during the night is a sign of a relapse or of an exacer- 
bation of the inflammatory trouble. Examination of the eye the 
next morning shows fresh fibrinous exudate in the anterior 
chamber, or the presence of a fresh hyperemia. Such acute at- 
tacks of pain are usually of short duration. Metastatic gonorrheal 
iritis is a tyj)e of iritis which causes the mpst intense and obstinate 
pain. The referred pain, as a rule, is in the frontotemporal, 
maxillary and temporal areas. Should the tension in the vitreous 
chamber rise, the pain has a tendency to be referred further back, 
and also, in some cases, the teeth of the upper and even of the 
lower jaw may become painful and very sensitive to pressure. 

Rest in bed, atropin, warm applications, dionin, and diapho- 
resis are serviceable for all forms of iritis. If the pain is very 
intense aspirin, pyramidon, or morphin must be given, and even 
these analgesics may jDrove insufficient to relieve the pain. In 
chronic iritis and iridocyclitis the pain is generally very moder- 
ate. Circumscribed areas in the region of the ciliary body, which 
are tender to pressure, can be sometimes detected. They probably 
correspond to small inflammatory foci which do not cause any 
other clinical symptoms. It is important to ascertain their pres- 
ence, as they direct attention to the possible recurrence of the 

A sudden exacerbation of pain in an acute or a chronic iritis 
should always arouse the suspicion that a secondary glaucoma is 
developing. The pain caused by such an attack of secondary glau- 
coma can reach the highest possible degTee. The increase of intra- 
ocular tension is diagnostic for acute glaucoma, although the dif- 


ferential diagnosis between a primary and a secondary glaucoma 
may be very difficnlt, esjDecially when the cornea is dull and 

A painful condition, which closely resembles iritis, and which 
is in direct contrast to glaucoma, is an acute hypotonia of the 
globe, complicating detachment of the retina. Hypotonia of this 
kind can exist without any pain. In very pronounced and acute 
cases, however, pain appears. To this subjective symptom there 
corresponds an objective change, consisting of a slight ciliary in- 
jection of the globe, a deepening of the anterior chamber and a 
tremulous condition of both iris and lens. The vitreous is gener- 
ally very turbid, and jjermits only indistinct recognition of the 
increase of a preexisting or the first appearance of a retinal de- 
tachment which previously had not existed. The pain, as a rule, 
is mild and, together with other symptoms, slowly disappears. 

In the course of retinal detachment there also occurs another 
painful process, i.e., an iritis, which, similarly to the detachment, 
is a consequence of the high myopia. If pain appears in the eye 
affected with posterior staphyloma iritis might be present. Such 
myopic iritis seldom appears in posterior staphyloma without in- 
volvement of the retina, and may be a precursory symptom of this 
grave affection. 

Sclerotic Coat. — Areas, tender to pressure, similar to those 
previously described as occurring in chronic iritis, but correspond- 
ing to hyperemic and swollen areas of the sclerotic, are characteris- 
tic for scleritis. This affection may cause violent, spontaneous 
pain, but may also be absolutely indolent. It is not exactly known 
Avhy some cases of scleritis are very painful and others are not. 
This certainly does not depend upon the etiology, as both forms 
may be caused by the same etiological factors. Anatomical inves- 
tigation (Oatman) may explain it. In some cases the ciliary 
nerves, as they pass through the foci of the scleritis, remain nor- 
mal; while in others they are infiltrated by leukocytes. The in- 
filtrated nerves show the anatomical picture of a neuritis, and 
this is probably the cause of the pain. 

Inflammatory foci of the scleritis may be invisible, on account 


of chemosis. If such, is the case, palpation of the globe will easily 
disclose the situation of the sclerotic foci. A sclerotic infiltration, 
situated under one of the muscles, or at a muscular insertion, will 
be irritated by contraction of the muscles and cause pain in move- 
ments of the eye. 

Similar pain following eye movements may be the sign of 
rheumatism of an eye-muscle. The diagnosis of this condition is 
based on the subjective symptom of pain without any visible 
changes. Diplopia as a sign of impaired movement is, however, 
not present in these cases of rheumatism. 

Choroid, Retina and Optic Nerve. — Inflammation of the inter- 
nal membranes of the eye, choroid and retina, as well as inflam- 
mation of the optic nerve, generally does not give rise to pain. 
Acute retrobulbar neuritis is an exception. Dull pain in the 
orbit, increasing on extreme or violent movement of the eye, or 
on pressure upon the globe, and associated with rapidly increasing 
amblyopia and negative ophthalmoscopic findings, is the chief 
symjJtom upon which the diagnosis is founded. A similar deep 
pain on pressure occurs in posterior scleritis, which sometimes 
shows an intermittent exophthalmos, and also in periostitis or em- 
pyema of the posterior ethmoidal cells. 

Bulb.- — Pain originating in phthisic eyes deserves especial 
attention and may arise from different causes. In most cases it 
is due to increase of pressure of the jDrocess which originally 
caused the j^hthisis, and is of the greatest importance, because a 
reappearance of a previous inflammation may produce a sympa- 
thetic affection of the other eye. Therefore, it cannot be expressed 
too strongly that all phthisical globes which cause spontaneous pain 
ought to be removed. 

Up to the present time no symptom is kno^^^l permitting a 
differential diag-nosis between an eye apt to induce sympathetic 
ophthalmia from those which are harmless. Great attention must 
be given to the other eye. Dull pain in the healthy eye may be 
the first symptom of a sympathetic trouble. The suspicion of a 
beginning process of this nature will be aroused, especially by the 
appearance of photophobia, ciliary hyperemia, and diminution of 


the range of accommodation. These symptoms, which have been 
described as sympathetic irritations, may precede the outbreak of 
an iridocyclitis for a varying period of time. Sympathetic 
ophthahnia may also begin without irritative symptoms. 

Sunken globes may become painful also from other reasons. 
Such are ossification of the choroid, which causes pressure upon 
the branches of the ciliary nerves, and folding of the sclerotic, 
which acts in the same manner. Attention may be directed to 
the fact that, even after the enucleation of a globe, the trunk of 
the optic nerve or its surroundings may be very painful to pres- 
sure, and is an indication for the resection of these parts in order 
to enable the patient to wear a shell. The cause of this pain is 
a neuroma of the ciliary nerves. 

Glaucoma. — The most violent pain which can exist in eye dis- 
eases is that found in acute glaucoma. The increase of intraocular 
tension and the consecutive pressure upon the nerves in all the 
tissues of the globe are given as the explanation of this pain. 
Radiation of pain into different distributing areas of the trigemi- 
nus is quite frequent, and has caused the condition to be mistaken 
for a neuralgia, a hemicrania, a toothache, or, when vomiting is 
present, even for a meningitis. It is unnecessary to analyze the 
nature of an acute attack of glaucoma. It should be remembered 
that inexplicable pain in the first branch of the fifth nerve is 
frequently a symptom of glaucoma ; either prodromal or the devel- 
oped disease. No doubt neuralgia may precede the outbreak of an 
acute glaucoma by months or years. This pressure may be reduced 
(with consequent relief of pain) by miotics. The diminution of 
intraocular pressure due to miotics may be considerably enhanced 
by the use of one per cent, solution of morphin, used as a collyrium 
simultaneously with the miotics. Eserin is excellent in subduing 
pain caused by glaucoma. If, however, it is instilled into a nor- 
mal eye it is liable to cause considerable pain. This is due to 
the compression of the nerve fibers by the tonic contraction of the 
sphincter of the pupil. This pain may be quickly removed by 
the use of a mydriatic. 

Iridectomy and other operations devised to replace iridectomy 


alleviate the pain rapidly when they reduce the ocular tension. If 
after an operation for glaucoma intense pain arises, or an increase 
of pressure is noted, it is a symptom indicating the malignancy 
of the glaucoma, and forebodes the loss of the eye. If the eye 
is blind and painful from glaucoma one may attempt to relieve 
the pain by anti-giaucomatous operations, if they are possible; 
otherwise, there remains only opticociliary neurotomy or enuclea- 
tion of the globe. The operation first referred to is a dangerous 
undertaking, as its results are doubtful, and in many cases it 
must be followed by enucleation. 

Panophthalmitis. —Pain in panophthalmitis is caused in a 
similar manner to that of glaucoma. The presence of a focus 
of jDurulent inflammation in the globe, with the consequent pres- 
sure, explains the painfulness of the disease. That the simple 
opening of the globe by incision or spontaneous perforation at 
once considerably relieves the pain proves that increase of pressure 
due to the purulent exudation plays a great part in the etiology 
of pain in panophthalmitis. 

Asthenopic Disorders. — An entirely different group of painful 
conditions is met with in the asthenopic disorders and the closely 
related cases of eye-strain. In both accommodative and muscular 
asthenopias, whether the latter be caused by exophoria or insuffi- 
ciency of convergence, the phenomena are blurring of objects and 
a dull pain in the forehead. This is accompanied by a feeling of 
heaviness and pressure in the eyelids, lacrymation and a sensation 
of heat in the eyes. If, in spite of these symptoms, the eyes 
are used for work, headache may ap]3ear and continue even during 
the next day. Asthenopic disorders manifest themselves, as 
a rule, in the late afternoon or in the evening, when the 
muscular apparatus is tired by the day's work. Proper glasses or 
prisms can totally suppress the trouble, or at least alleviate it con- 
siderably. In muscular asthenopia stereoscopic exercises can also 
be of benefit. 

How far a low degree of astigmatism may cause trouble is not 
quite determined. Most of the European oculists are sceptical in 
regard to this question, whereas English and American oculists, 


especially the latter, attribute a great number of subjective dis- 
orders to uncorrected or insufficiently corrected astigmatism. They 
also have created and developed the term "eye-strain," to which 
disturbances in all parts of the organism are ascribed. Disturb- 
ances due to hyperphoria are less frequent than simple asthenopic 
phenomena, and differ from muscular asthenopia in exophoria, in 
that they trouble the patient not only in close work, but cause 
incessant aching. The prescription of corresponding prisms with 
the apices upward and downward suppresses such disorders 

To Bielschowsky we owe the knowledge of a rare group of 
painful disturbances related closely to asthenopia. This author 
has discovered cases of disturbed innervation of binocular vision 
leading to considerable subjective disturbances and simulating 
squints. Their treatment either by operation or drugs is rarely 

In hyperopics the over-strained accommodation leads to asthen- 
opia. Disturbances caused by straining of the accommodation 
do not occur in myopics, who, nevertheless, experience disagree- 
able sensations. Myopics of the middle and higher grades fre- 
quently complain of pain in their eyes when they use them for 
close work. This pain, which is intermittent but not severe, may 
yet be very troublesome to sensitive and neurasthenic individuals. 

'No generally accepted explanation of this kind of pain exists, 
but it would seem quite plausible to connect it with the process of 
stretching of the sclerotic, which may also affect the nerves lying 
in the sclera. This pain cannot be influenced by the wearing of 
correcting glasses, or by the extractions of the lens for removal 
of the myopia. 



It passes as current fact among the laity that ear pains can 
scarcely be surpassed in severity by any pain elsewhere in the 
body. Relief may be secured from pain occurring in any part of 
the external or middle ear, but not from pain of labyrinthine 

External Ear. — Trauma of the external ear is scarcely more 
painful than trauma in other parts of the body, but it may be 
followed by two troublesome conditions, namely, othematoma and 
perichondritis. Othematoma is an exudate of serous, bloody fluid 
between the cartilage and perichondrium of the ear. It results 
from a blow, especially one from a fist. Consequently, we find 
it frequently among prizefighters, and perhaps most frequently 
among the Japanese wrestlers, because they use the head and neck 
against the head of an opponent, and in this way the ear often 
becomes subject to very great pressure, giving rise to the above- 
mentioned exudate. It also is frequently seen among patients suf- 
fering from acute mental disturbances. 

The pain in hematoma is usually trifling. It is mostly of a 
dull, aching character, worse at night. If, however, the othema- 
toma becomes infected through unskilful surgery, a very painful 
perichondritis may follow. 

Such a perichondritis arises sometimes, also, after a radical 
operation, as a result of infection of the cartilage. This cannot 
always be avoided in plastic work upon the external ear. If the 
bacillus pyocyaneus is present in the middle ear secretion, this 
germ, which has a fondness for attacking cartilage, may bring 

1 By Dr. Ruttin, assistant in the Ear Clinic of the University of Vienna. 


about a perichondritis. In fact, one can always grow the bacillus 
pyocyaneus in pure culture from the perichondritic secretion. 
Such a perichondritis advances very slowly, and lasts about 
four weeks, when the disease has reached its highest point. The 
suppuration then ceases, and the cartilage begins to shrink. Un- 
fortunately, early and energetic incision does not shorten its 
course. During the period of development, to the beginning of 
the shrinking of the cartilage, extraordinarily severe pains exist. 
It often requires much persuasion to convince the patient that 
this distressing condition is not dangerous. 

Of the tumors of the external ear, carcinoma and sarcoma 
sometimes give rise to severe pains, but they often run a painless 
course. The same is true of the inflammatory granulomata of 
lupus and lues, in which the slight pain may be completely over- 
shadowed by the itching. 

Pain of the external ear clue to frostbite is especially note- 
worthy. It is peculiar in that it is likely to recur with every 
return of cold weather. The previously frozen parts often begin 
to be painful again, even with a moderate fall of temperature. 

A very j)ainful disturbance in the pinna, which is, to be sure, 
only a symptom of another disease, is herpes. The pain begins 
even before the appearance of the herpetic vesicles, and continues 
usually until they vanish. Grouty nodules, which have a prefer- 
ence for the helix margin of the pinna, may be the cause of 
pains which are of a very unstable and changing character, a 
peculiarity of gouty nodules in general. 

External Auditory Canal. — The external canal, with its nu- 
merous hairs and glands, is directly predisposed to furunculosis. 
The frequency of middle-ear suppuration, and the circumstances 
that such a condition, after only a short existence, in most cases 
shows a secondary infection with pyogenic staphylococcus, carries 
with it the probability that during the necessary cleaning manipula- 
tions of patient or physician the hair follicles become inoculated, 
a procedure which, according to the researches of Schimmelbusch, 
Garre and others, brings about furunculosis with tolerable cer- 


, Furuncle of the external canal manifests itself through a 
special painfulness, because the pus, on account of the closely 
woven, subcutaneous, connective tissues, is held under a high 
degree of pressure. These pains are of a boring, sticking, throb- 
bing nature, and radiate, by preference, toward the teeth. There- 
fore, the patient can take only a very limited amount of nourish- 
ment, since every movement of the mouth increases the pain. 
This is due to the fact that the head of the inferior maxilla lies 
against the anterior wall of the external auditory canal, and 
movements of the jaw joint are accompanied by movements of 
the adjacent aural tissues. The pain usually subsides with the 
rupture of the furuncle, or with its opening. 

The pain of diffuse inflammation in the external canal, the 
so-called otitis externa diffusa, is of longer duration, and much 
less certainly influenced by operation. 

Foreign bodies in the external auditory canal cause pain 
usually only by penetration, by wounds brought about by unskil- 
ful attempts to dislodge them, or by the swelling or growing of 
the foreign body in the ear. Peas, beans and fruit kernels 
remaining for some time in the canal swell, and cause a 
very noticeable pressure upon the canal wall, thereby producing 
more or less pain. The larvae of the large meat-fly ("blue-bottle 
fly"), developing from eggs laid in the canal, often attain great- 
ness, both in number and in size. They may cause such pressure 
upon the external canal that it becomes widened to the breadth of 
a finger. Since these maggots are provided with sharp hooks at 
the ends of their bodies, and seek to attach themselves by sticking 
these hooks into the skin, the pain which they produce is extraor- 
dinarily severe. This becomes still greater, because the worm 
masses are always in motion, and consequently the pain is of a 
continuous, changing, undulating character. I have observed such 
a case, in which twenty-six maggots had brought about a consider- 
able widening of the canal, with very intense pain. 

In lesions of the middle ear the patient assumes a position in 
which the ear of the affected side rests in the palm of a supporting 
hand, the elbow resting on a table, as is illustrated in Fig. 80. 



Tympanum. — Pains may originate in the drum membrane. 
One often speaks here of a myringitis bullosa. This is, however, 
not a bacterial invasion, but is only a herpes of the drum. Bac- 
teriological examination in large numbers of such cases showed 
the vesicles to be sterile. The sudden beginning of the pain is 
very characteristic for myringitis. Often the patient is awakened 
at night by a sudden, severe, sticking pain in an ear previously 
entirely sound. The pain 
lasts as long as the vesicle 
remains, but ceases just as 
suddenly as it began. ^ 

In lesions of the exter- 
nal meatus from the tym- 
panum outward the pain is 
localized to the diseased 
area, but from the drum in- 
ward the pain is, as a rule, 
referred to a distant area, 
the most common reference 
area being the hyoid, which 
has two points of maximum 
tenderness, the first in the 
meatus and the second just 
behind the angle of the jaw. 
These areas are also asso- 
ciated with the tonsil, the 
posterior teeth of the lower 
jaw, and the lateral aspects 
of the tongue (Head). When the tension in the middle ear is 
raised pain may also be referred to the vertical and parietal area 
of the scalp. (See pages 293 and 294.) 

Middle-ear Disease. — Acute Otitis Media. — Most marked 
are the jDains of acute middle-ear inflammation. Here they are 
not limited to the membrana tympani, and are most severe until 

' Hunt, of New York, has shown that this type of herpes is usually 
associated with disease of the geniculate ganglion. 

Fig. 80. — Posture Assumed in Earache 


perforation of the drum takes place. We must, however, differ- 
entiate two kinds of acute otitis, namely, that caused bj capsulated 
bacilli, and that caused by noncapsulated bacilli. "While in the 
first type the pain is usually trifling in nature, and only "stick- 
ing" in the first day of the disease, as in middle-ear catarrh, the 
second type, caused by noncapsulated cocci, calls forth the most 
capricious and troublesome symptoms. The pains begin with 
moderate intensity and increase, within two or three days, to 
quite unusual severity. They are, as a rule, of a boring, sticking or 
tearing nature, and reach the gTcatest degree when the drum mem- 
brane becomes deep red, shows no details, and is nearly ready to 
rupture at some markedly bulging spot. After rupture the pain 
for the most part ceases. Obviously one can shorten the patient's 
sufferings by carrying out artificial rupture of the drum through 
incision (paracentesis). It must be regarded as an unfavorable 
sign, if, after perforation of the drum, the pains do not immedi- 
ately subside. In such cases the mastoid process is likely to be 
included, and if this comes to pass spontaneous pains of greater 
or less severity manifest themselves. However, this symptom may 
be completely lacking, or may only be elicited by pressure, either 
upon the mastoid tip or over the antrmn, in which latter case 
the mastoid cells are undoubtedly involved. To be sure the prop- 
agation of the inflammation to this degTee must depend upon the 
anatomical structure of the mastoid process. A pneumatic mas- 
toid is always affected in the beginning of an acute otitis, and 
this is the reason why tenderness at the tip in such cases is so 
frequently seen. But this inflammation may at any stage retro- 
gress without going on to suppuration and, therefore, in the begin- 
ning of an acute otitis this symptom has no pathognomonic sig- 
nificance. If, however, the tenderness or the spontaneous pains 
last a relatively long time, or if, after having once vanished, 
they reappear, then it is probable that we have to do with an 
abscess in the mastoid process, and in this regard the symptom 
becomes of great importance with respect to operative inter- 

Cheoxic middle-eae disciiaege causes, as a rule, no pain; 


but pain may arise, of course, as a result of an acute exacerba- 
tion, or if the perforation in tbe drum is so small that opportunity 
is given for retention of pus. Sometimes chronic middle-ear sup- 
puration, which otherwise would give no pain, is, when accom- 
panied by cholesteatoma, subject to manifestation of severe pain. 

Complications of Middle-eak Disease. — If acute or 
chronic middle-ear suppuration becomes complicated by extension 
of the inflammation to neighboring regions, then the pain thus pro- 
duced is usually quite significant, especially if suppuration takes 
place in the mastoid, whereby the mastoid cells are broken down 
and the excavated interior of this bone becomes filled by pus, 
which, through gTadual accumulation, exerts great pressure. If 
this pus breaks externally through the bone cortex, it can dissect the 
periosteum free from the bone to a very great extent. We then 
find a large swelling behind the ear, which is covered by a much- 
reddened, very tense epidermis, giving rise to great pain. This 
swelling may become so great that the entire half of the head is in- 
volved, especially in badly neglected eases. This subperiosteal ab- 
scess formation is very frequent in children, because the pus passes 
through the open fissura mastoidea in a very short time, and then 
lies directly under the periosteum ; but here, on the other hand, 
instead of producing pain, the pain may be actually lessened 
after penetration to the periosteum for a time, at least, through 
relief of pressure Avithin the mastoid shell. 

If, however, the pus burrows inward, the dura becomes ex- 
posed through destruction of bone, either in the posterior or mid- 
dle fossa, according to the direction which the destructive process 
takes. The tough dura and, in the posterior fossa, the sinus lat- 
eralis are fairly resistant structures, and may often be sur- 
rounded by pus for a long time without becoming especially af- 
fected. They become covered with granulations, which serve further 
to protect them, and thus are brought about the conditions known 
as pachymeningitis externa, or periphlebitis of the lateral sinus, 
as the case may be. With this disease-picture at hand, the pain 
is likely to be of a trifling, ill-defined, dull nature, but if the pus 
extends outward between the dura and the bone, or between the 


sinus and the bone, we have the picture either of an extradural 
or of a perisinus abscess. We speak of a "closed" extradural 
abscess if the opening through which the pus has penetrated to 
the dura is so small as to be nearly undemonstrable ; but if, on 
the other hand, the communication with the purulent mastoid 
cavity is greater, we speak of such a condition as an "open" 
extradural abscess. J^aturally the pain in a closed extradural 
abscess is much more severe than in the open type. If the pus 
spreads out toward the tip of the petrous portion of the temporal, 
then periorbital pains often arise, which JSTeumann holds to be 
characteristic for this type of extradural abscess. On the con- 
trary, if the abscess spreads more laterally in the middle fossa 
of the skull, pain and swelling in the temporal region near the 
zygomatic process simultaneously arise, as Ruttin has described. 

Perisinus abscess may also cause very severe pain, especially 
if the pus collects in the bony sinus groove between the mem- 
branous and bony sinus walls, where it often remains under such 
high pressure that, upon opening the mastoid process, it gushes 
forth in a pulsating stream. Still greater may the pain become, 
if, besides the pus, gas forms (gas abscess), and raises the pres- 
sure to a very high degree. Perisinus abscess, like extradural 
abscess in the posterior fossa, causes a more or less severe head- 
ache in the occipital region. If the suppuration destroys the dura 
mater, then intradural suppuration, meningitis, temporal lobe 
abscess, cerebellar abscess, or sinus thrombosis may arise. 

Intradural suppuration is such a rarity, and so seldom clinic- 
ally pure in type, that with respect to pain as a symptom it offers 
very little that is characteristic. On the contrary, otogenic men- 
ingitis may produce a tolerably pronounced picture, since in it the 
pain is extraordinarily intense, of a sticking or tearing character, 
and accentuated in its last phase. I am accustomed to describe this 
to my students in the following manner : The location of this pain 
varies according to the extension of the meningitis. The basal type 
usually causes occipital or frontal headache, but the head type, that 
is, the form of suppuration which spreads out over the convexity of 
the brain, produces pain at the vertex of the skull. Character- 


istic, also, of meningitis are the remissions of pain, great suffering 
being often followed by a period of comparative ease and comfort. 

Brain abscesses may also exist in the middle and posterior 
fossae. Headache is seldom lacking in these cases, and may be 
referred, in both cerebellar and temporal-lobe abscesses, to the 
frontal or occipital regions. In temporal-lobe abscess it is not 
seldom localized at the vertex of the skull, but in both temporal- 
lobe and cerebellar abscesses the pain is usually limited to the 
half side of the head — hemicrania. 

Middle-ear Catarrh. — Middle-ear catarrh is a frequent cause 
of pain, especially in children. This pain, to be sure, is not 
especially intense, but may, through its sticking character, be 
quite disagreeable. It seems that such pains are induced 
through the strong retraction of the membrana tympani ; at least, 
this is true of those cases in which the drum is markedly re- 
tracted, for they vanish after inflation of the tympanic cavity, or 
after aspiration through the external auditory canal. High- 
grade inveterate catarrh, with maximal retraction of the drum, 
which is of a milky color, also causes pain, which is not, how- 
ever, to be influenced through Politzerization, catheterization or 
massage, because the drum is fixed in the retracted position and 
cannot be corrected through these manipulations. In these cases 
the pain, nevertheless, ceases immediately if one introduces a hook 
with a straight shank just in front of the hammer and draws the 
entire membrane outward, after the method which Euttin has 

Otosclerosis. — In this disease, which consists of pathological 
changes in the bony labyrinth capsule and which has an exquisite 
hereditary anamnesis, but whose etiology is still unknown, pains 
are seldom to be found. However, there exist, sometimes, in addi- 
tion to diminished hearing, noises and manifold paresthesias 
localized or diffused through the entire ear tract, as well as pain- 
ful sensations in the external canal, and in the surrounding struc- 

Labyrinth. — Whether pains of distinctly labyrinthine origin 
are to be recognized or not has hitherto not certainly been proven. 


However, pains in labyrinth disease scarcely come into considera- 
tion in relation to the other extraordinarily troublesome and dis- 
tressing symptoms, such as difficulty of hearing, noises, dizziness, 
vomiting, etc. 

Referred Pains. — First of all, there are pains due to diseased 
teeth, which may so closely simulate aural pains that a tyj)ical 
disease-picture is described as otalgia excarie dentium, since a 
bad tooth is so often the cause of a pain described by the patient 
as localized in the ear. Secondly, swollen glands in the neck 
region may produce pains which the patient falsely refers to the 
ear on the side affected. Especially, however, do inflammations 
in or around the tonsils (peritonsillar abscess) produce pains 
which the patient describes with great certainty as being situated 
in the ear. These pains are increased by every act of swallow- 
ing, because muscles of the Eustachian tube are thus brought into 



The Sensory Nerves of the Nose. — The uose receives its sensi- 
bility from the first two branches of the trigeminus. The lateral 
wall receiving its sensory supply from the anterior and posterior 
ethmoidal nerves, which take their origin from the first branch 
of the trigeminus, while the infraorbital and sphenopalatine 
nerves, which come from the second branch, participate in the 
innervation of the other parts. The nervi septinarinm, which 
are the sensory nerves of the septum, also have their origin in 
the second branch of the fifth nerve. Of the sinuses the frontal 
sinus and the anterior ethmoidal cells receive their nerve supply 
from the ophthalmic ramus (trigeminus I), while the posterior 
ethmoidal cells and the sj)henoidal sinus are supplied by the nervi 
nasalis lateralis superiores and the nervi ethmoidales posteriores. 

The exact relations, according to the description of Zucker- 
kandl, are the following : The nervus nasalis anterior passes 
through the foramen ethmoidale anticum toward the anterior 
cavity of the skull, where it extends to the edge of the cribriform 
plate toward the anterior portion, and is there covered by the 
hard sheath of the dura mater; then, after passing through the 
ethmoidal canal, it goes to the nasal cavity, where it divides into 
the ramus septinarinm, the ramus lateralis, and the ramus an- 
terior. The posterior nerves of the nose are derived from the 
sphenopalatine ganglion, and after passing through the fora- 
men enter the nasal cavity, where they are distributed to the 
lateral and median wall. The nervus nasopalatinum scarpi, the 

1 By Privat Accent Dr. Emit Glas, assistant in the University Clinic in 
Vienna (Director Hofrat Chiari). 



true septum nerve, which originates from the same source, sup- 
plies the anterior mucous membrane of the palate after having 
passed through the canalis incisorus. 

Diseases Which Produce Pain and Their Manner of Produc- 
tion. — Introitus narium, folliculitis, eczema introitus, and the spe- 
cific inflammations in the region of the anterior portions of the 
septum produce pains such as one finds in all inflammations, and 
need no special explanation. One should never forget, in acute 
pains arising suddenly in the region of the introitus, closely to 
inspect the anterior angle of the entrance of the nose, for in this 
place one often finds a hidden folliculitis, or a small retention of 
pus, which may easily produce severe pain. This is of 
special importance in case of erysipelas, which not infrequently 
begins at the introitus narium. It is well to mention the septum 
abscesses, which are always accompanied by severe pains, and are 
most frequently of traumatic origin. Pains in the region of the 
cartilaginous portion of the nasal septum, combined with a sten- 
osis of traumatic origin, at the nasal entrance, point to the forma- 
tion of a septum abscess. The pains may be caused either 
through inflammatory irritation of the terminal ramification of 
the septal nerves, through compression or degeneration, or through 
pressure from the suppurating hematoma. Long, persistent 
pains, after a discontinuation of suppuration, point to a fracture 
or to a spreading of the fissures of the skull. 

Nasal Stenosis. — The various headaches that are caused by 
nasal stenosis deserve special consideration, for they are often 
accompanied by other phenomena, such as psychical depression, 
inattentiveness, loss of appetite, neurasthenic symptoms, and lack 
of concentration. These phenomena, which were mentioned by 
Piorry as symptoms of rhinostenoma, are caused by nasal polypi, 
large hypertrophies, higher grade septum deviations, and tumors 
of the nose, and can be cured by endonasal therapy. 

Hartmann, in his work on "Nasal Headaches and ]!^asal !N^eu- 
rasthenia," has given the following explanation for headaches 
caused by nasal stenosis : If too little oxygen passes into the 
lungs through a partly stenosed nose, and consequently a diminu- 


tion of exhaled air, as is physiologically necessary, occurs, the 
oxygen content of the blood is diminished and an accninnla- 
tion of carbon dioxid takes place in the blood. It is not only the 
accumulation of carbon dioxid that is to be considered, but there 
are other by-products formed that are classed as toxins. Hart- 
mann states that, through partaking of poor nutritive matter, a 
bad influence is produced upon the nervous organism, and that 
only in this way is the appearance of headaches and neuras- 
thenic symptoms to be explained. Just as neurasthenic condi- 
tions appear in persons who are crowded into closed or poorly 
ventilated apartments, so, also, difficulties are called forth through 
lack of nasal breathing-space. 

In children with adenoid vegetations Lichtwitz and La- 
brayes have proven that the oxygen of the blood and the number 
of red blood-corpuscles are considerably reduced, while the white 
ones are increased; and that, upon removal of the adenoids, the 
number of red corpuscles and the oxygen constituents of the 
blood are heightened. This change, especially, should be consid- 
ered by those who do not estimate highly enough the importance 
of adenoids, and who deny the disappearance of a number of 
reflex symptoms after the nasal pharynx has been freed of its 
encumbrances. The headaches produced by nasal stenosis can, 
in most cases, be cured through operative procedures. However, 
one must not forget that quite a number of internal diseases may 
also produce these cephalalgias, which fact should receive consider- 
ation in applying therapeutic measures (see Headache, Chapter 
XIV, page 262). 

Empyema. — The headaches arising in empyemas of the sinuses 
are found in acute as well as in chronic empyemas, and each has 
a different genesis. Should it be possible that, at the same time 
with the inflammatory changes of the sinus mucous membrane, the 
terminal ramifications of the sensory nerve apparatus also suffer 
inflammatory changes ; or should it -be possible that distant in- 
fluences might also be acting as causative factors (the latter be- 
ing classified in the group of referred pains), only after exclusion 
of these factors is it proper to think of the neuralgic pains, which, 


arising in cases of empyema, can be traced back to a stasis of 
secretion and secondary pressure phenomena. The other neu- 
ralgic pains caused by nasal affections will be considered in regular 

In his work on "The Sig-nificance of Rhinology for Internal 
Diagnosis and Therapy" Glas has especially called attention 
to and emphasized the fact that often the cause of these headaches 
is not discovered for a long time, and that all possible measures 
to relieve the sufferings may be utilized without result. 

Other pains found in inflammatory states of the sinus are the 
local pains that occur in the cavities themselves, as aching, boring 
and piercing pains, and occasionally, as in cases of stasis, 
severe and throbbing pains. These pains, which are similar to 
sinus abscess pains, may also be produced by percussion of the 
external wall of the suspected sinus, or, if previously existing, 
may be increased. In this way in those sinuses whose walls are 
percussible (as the maxillary sinus, frontal sinus and anterior 
ethmoidal cells) one is able to decide, in some cases, even the 
extent of the diseased area, and the size of the diseased sinus. 
Occasionally, through the detection of percussion pains, one 
can determine whether there are abscess formations and septum 
deviations in the frontal sinus. These observations may be sub- 
stantiated by X-ray examinations. 

Finally, pains arising in other parts of the body may be 
genetically related to diseases of the nose, especially to empyema, 
as described by Flies in several cases. These phenomena belong 
to the large group of reflex neuroses of the nose. A careful study 
of these pain reflexes has also been made by Head, who finds 
that diseases of the olfactory (upper part of the nose) cause re- 
ferred pain and superficial tenderness over the nasal and mid- 
orbital areas (q. v.) : disease of the nasopharyngeal part of 
the respiratory tract may cause pain and tenderness in the 
nasolabial area. But, as a rule, the nasal afl'ections do not 
cause pain. Since the pressure pains are of value for the 
localization of the diseased areas, the statement of the patient 
in regard to the location of the headache would be of special diag- 


nostic importance, were it not for the fact that there are many 
cases in which the subjective sensations do not coincide with the 
objective findings. Similarly, one often finds that patients with 
a disease of the sphenoid sinus or posterior ethmoidal cells often 
refer the pains to the region of the anterior sinnses, which, upon 
examination, are found perfectly healthy, and vice versa; so 
that one cannot use pain localization as an absolute indicator in 
the topical diagnosis of diseased sinuses. 

That neuralgias may be produced by suppuration of the sinuses 
has been proven by Peyre, who had a case of facial neuralgia, 
which had been complicated by the removal of the Gasserian gan- 
glion, and which disappeared after a septum and maxillary sinus 
operation ; or by Hartmann, who had a case of trigeminus neu- 
ralgia, accompanied by insomnia of several weeks' duration, which 
was completely cured after removing a caseous mass from the 
antrum. The writer is at present observing a case of intensive 
infraorbital neuralgia of several weeks' duration, which was 
treated galvanically without result, and which completely disap- 
])eared after Cowper's alveolar operation of the maxillary sinus. 
Also, cases of frontal sinus empyema, accompanied by supraorbital 
neuralgias, are not infrequently cured by operation. 

Headache from Disease of the Sphenopalatine Ganglion. — The 
experiments of Greenfield Seiider, who believes that the spheno- 
palatine ganglion is an important factor in the production of head- 
aches of nasal origin, are of much interest. He believes that, sec- 
ondarily, the ganglion is sympathetically affected in intranasal in- 
flammation, and applies his therapeutic measures accordingly. He 
has tried to anesthetize the ganglion by making cocain applica- 
tion behind the posterior end of the middle turbinate, and suc- 
ceeded in several of his cases. At the same time he describes 
cases in which headaches have disappeared after cauterization of 
these areas,- a fact which seems to point to an affection of the 

Obstructed Sinuses. — Here we may consider the observations 
which convince the writer, as well as Hartmann, that also in cases 
of nondiseased, but obstructed, sinuses, or in cases of poor com- 


miinication between the sinuses and the nose, severe pains* may 
exist, which, upon removal of the obstructions, are immediately 
decreased, I know of a colleague whose left maxillary sinus 
I must puncture four or five times a year, without being able 
to detect at any time any inflammatory affection of the antrum. 
However, I noticed at the first j)uncture that I made, on account 
of the severe, one-sided headache, that by the inflation of the 
antrum with air the characteristic antrum murmur was missing, 
and that it took more pressure than normal to inflate ; therefore, I 
was forced to conclude that the ostium relations were unsatisfac- 
tory, and were either injured or had been insufiiciently developed. 
Although there was no secretion to be found in the return solution 
after douching the antrum, nevertheless the colleague felt well 
after the rinsing. The headaches disappeared for some time, until 
the conditions demanded another puncture, which had to be re- 
peated four or five times a year. The patient has not accepted 
my proposition to enlarge the communication and thus relieve him 
of his sufferings, although this operation might free him of his 
pains forever. Such cases indicate that the destruction of the 
communication, or a hindrance between the sinuses and the nose, 
can produce headaches even where there is no sinusitis present. 

Hartmann has also made similar observations, and gives the 
following explanation to prove the truth of his assertion: (1) 
In those cases in which existing frontal headaches cause one to 
believe that there is a frontal sinus disease, the frontal sinus may 
be opened without finding any diseased condition. In such 
cases the pains may disappear after opening the frontal sinus, to 
reappear, however, when the external opening heals, unless in the 
meantime a communication has been made with the nose. If a 
communication has been made, the pains are absent as long as the 
communication exists. 

(2) There are cases in which, after an operation on the 
frontal sinus, exacerbatory symptoms arise in the form of head- 
aches without a real recrudescence of the disease, but only a clo- 
sure of the opening into the nose, and it is this closure which pro- 
duced the frontal headaches. In such case it suffices to open the 


thin scar on the forehead with a sound. This allows the entrance 
of air, and thus relieves the headaches. 

(3) The third deduction of Hartmann's is not absolutely 
unchallengeable, for in those cases in which an empyema had ex- 
isted (about eight), and which were cured, the reason that the 
headaches disappeared after the formation of a communication 
between the nose and the frontal sinus can be traced, possibly, to 
a retention of secretion, and not to the exclusion of air in the sinus. 

Tumors. — Headaches are, furthermore, a very important 
symptom, and are often the most prominent phenomena observed 
in the malignant tumors of the nose. Harmen and Glas have 
shown that the headache was the most important symptom in nine 
out of thirty-two cases observed.^ These headaches, in spite of 
the better drainage of the pus, the result of an existing empyema, 
continued in the same degree after the removal of the growth. This 
showed that a deeper affection must have been the cause. The two 
following cases may prove the truth of this assertion: (1) Pa- 
tient Z came, for dispensary treatment, with severe pains of the 
right cheek, accompanied by periodic, right-sided headaches. 
Rhinoscopical examination showed pus in the right nostril, espe- 
cially in the middle meatus. Considerable pain Avas present upon 
pressure on the right maxillary sinus wall. The probable diag- 
nosis made at the time was empyema of the antrum. Puncture 
of the right maxillary sinus was positive. Since the suppuration 
was not lessened by repeated douching through the ostium, the 
maxillary sinus was opened, through the alveolar process. Re- 
peated douching was given. ISTevertheless, the pain did not cease. 
The continuation of the pains, in spite of the opening and the 
douching of the antrum, indicated that another process must be 
present besides that of empyema. The histological examination 
of the resected lower turbinate showed cylindrical-celled carci- 

(2) A woman, fifty years of age, had a polypus removed 
from the right nostril a year previous to her admittance. Eight 
months later, on account of profuse suppuration, the maxillary 

1 Deutsche Festschrift fiir Chirurgie. 


sinus was opened through the alveolus. In this case there were 
two factors which indicated the probability of a malignant for- 
mation of new tissue, namely, the intense pain and the fetid con- 
dition of the returning fluid of the douching solution. The his- 
tological examination of an excised mass then gave the diagnosis 
of stratified epithelioma. 

The cause of the headaches in malignant tumors of the nose 
may be various. The origin may be one of the following: (1) 
reflex irritability, (2) blood and lymj)h stasis, (3) nerve pressure, 
(4) meningeal irritation, (5) the result of an empyema occurring 
at the same time. 

Zuckerkandl shows, in his anatomy of the nose, the superficial 
position of the ethmoidal nerve in the anterior portion of the 
skull, and adds that this exposed position allows approximating 
swellings to cause pressure symptoms. That headaches some- 
times arise as localized symptoms is sho-\vn in the second case, 
cited by Harmen and Glas in their article on "Malignant Tu- 
mors," in which right-sided, frontal headaches existed. Autopsy 
showed penetration of the roof of the orbit and a growth of the 
tumor into the right frontal sinus. We deduce, therefore, that, 
after cleansing of the sinuses, constant pains should call forth 
the suspicion of malignant neoplasms. In one of my last cases, 
on autopsy, I found a meningeal hyperemia, which may have been 
the cause of the violent and increasing cephalalgia during the 
last days of the patient's life. 

Finally, we cannot deny that those swollen areas in the interior 
of the mucous membrane, found on section, may, by compressing 
certain structures, very frequently be the cause of severe, continu- 
ous headaches. 


In cases of acute empyema the pains are sometimes very ^'io- 
lent, and one cannot be reminded too often of the fact that, when 
pains arise during a coryza, or an influenza, a thorough rhino- 
logical examination should be made. The result of therapeutic 
measures in empyema is often marvelous. A puncture through 


the inferior meatus, or a douching throngli the natural opening 
in sinusitis maxillaris, or the application of cocain on the 
anterior end of the middle turbinate, in frontal-sinus affections, 
can relieve the most acute pain. Unfortunately, even at the pres- 
ent time, one finds many cases which are treated for weeks, either 
galvanically, or faradically, are massaged, or receive other result- 
less treatment, without the attending physicians even surmising 
that the sinus is diseased. 

A test of importance, which I have introduced into rhinology, 
may frequently be applied. The principle of this test is the fol- 
lowing: The tuning fork, which is held anteriorly in the median 
line above the bridge of the nose, is lateralized to the side where 
the diseased sinus exists. In case the ear is not affected the 
patient hears the tuning fork only on the side, or more intensely 
on the side in which the sinus is affected. 

This method, which was tested in .several hundred cases, 
affords important service to one who is not thoroughly conversant 
with exact rhinological technic, as he is able to state, in cases of 
neuralgic headaches, whether they can be traced back to affections 
of the sinuses. I have seen cases in which patients complaining 
of severe neuralgias were sent to a rhinological specialist for 
examination, in whom Glas's tuning-fork test proved to be nega- 
tive (i. e., the tuning-fork was heard only at the point of appli- 
cation, or, as the patients said, heard alike at all parts of the 
head), and in whom, as a result of complete rhinological examina- 
tion, empyema could be excluded as the cause of the neuralgic 
pains. On the other hand, this test affords the rhinologist im- 
portant service in a diagnostic and prognostic manner, in regard 
to which Glas gave more explanatory details at the International 
Rhino-Laryngological Convention in Berlin, 1911. 

At the same time one must not forget those cases in which 
there is no stenosis, but in which hypertrophy of the middle tur- 
binate is the determining factor of the headaches, which disappear 
after resection of this part. These headaches are classed by 
some as symptoms of stenosis, but by others they are placed in 
the gi'oup of Flies' reflex symptoms. At any rate the pressure of 


the turbinates on the septi may cause reflex pains. The explana- 
tion of Casali, however, is more reasonable. He assumes the 
cause to be compression of the vessels of the nasal mucous mem- 
brane, which are in communication with the veins of the dura 
mater and the superior longitudinal sinus, the blood and lymph 
stasis of the mucous membrane of the nose causing a stasis in the 
dura covering the brain. There is no doubt that, in such cases, 
the result of resection of the hypertrophy of the turbinate is strik- 
ing. On negative internal findings, the diagnostic significance of 
this therapy should not be forgotten.- • Here may be included those 
cases in which severe neuralgias are relieved by endonasal opera- 
tions. In regard to this point, I have expressed myself in my 
work on "The Significance of Rhinology for Internal Diagnosis 
and Therapy," in the following manner: Any one who has had 
occasion to cure a severe neuralgia by an endonasal operation will 
know how to emphasize the importance, indeed the utmost neces- 
sity, of a rhinological examination in every case of neuralgia of 
the fifth nerve. The following cases may illustrate the foregoing 
statement : 

(1) In the case of a patient who had suffered for years with 
a neuralgia of the infraorbital nerve, I found, by rhinological 
examination, a rhinolith lying under the middle turbinate and 
pressing upon the processus uncinatus. On its removal the neu- 
ralgia disappeared. 

(2) A patient who had tried various therapeutic treatments 
for a trigeminal neuralgia, in his despair consulted a rhino] ogist. 
By chiseling a broad crista of the septum, which extended in an 
especially sharp angle to the middle turbinate, relief of the neu- 
ralgia was at once obtained. A single example of this kind is of 
more value than a multitude of reflections, and proves the utmost 
necessity of a rhinological examination of such cases. 

In conclusion, it may be added that som.etimes, after a radi- 
cal operation on the frontal sinus, neuralgias of the supraorbital 
nerve arise. Therefore, it seems rational that, while doing the 
Killian operation, one should remember this fact, and resect the 
supraorbital nerve. 




The sensory nerve of the pharynx is the linguaL From it are 
derived the sensory receptors of the anterior palatine arch, the 
tonsils, the floor of the mouth, and the tongue. This and the 
glosso-pharyngeal divide the supply of these parts, while the re- 
gion of the gingiva is supplied by the alveolaris inferior. 

Pain in Acute Diseases.— All the inflammatory processes in the 
region of the pharynx contribute toward pain production, for in- 
stance, the different forms of angina, the inflammation of the 
pharyngeal tonsil, retropharyngeal abscess, and herpes, febrile and 
zoster form. In this group of diseases phlegmonous angina, retro- 
pharyngeal abscess, and diphtheritic inflammation are especially 

Phlegmonous angina often produces very severe pain, which 
is increased by every movement of the mouth, and which has radia- 
tions in the ear which are often unbearable. These are sometimes 
produced through a pus area developing in the deeper tissues, 
sometimes through an inflammatory edema of the surroundings. 
The pains are sometimes boring, sticking, excessive, or trivial. 
The localization of the pain is frequently inexact. When it is 
located in the nasopharynx, in the ear, or in the region of the 
ostium tubse, - the increased pain iipon pressure outside on the 
anterior mandibular muscles is characteristic. 

Upon opening a peritonsillar abscess, the making of the inci- 
sion in the right place, that is, at the point where the pus comes 

* By Privat Docent Dr. Emil Glas, of Vienna University. 



nearest to the surface, is of the utmost importance, since the inci- 
sion and dilatation of the point of incision in an edematous 
but not pus infiltrated area occasion very severe pains, which fre- 
quently cause fainting. On the contrary, the incision in the in- 
filtrated area is relatively painless, and causes an instantaneous 

Retropliaryngeal abscess often produces pain similar to that 
of phlegmonous angina, save that in the former the location cor- 
responds to the deeper seat of the affection, which lies further 
back and lotver down. Deglutition also occasionally is difficult 
and is associated with severe pain, which is increased by the swell- 
ing of the corresponding glands of the neck. The acute process, 
as a rule, does not affect the vertebra, but chronic retropharyngeal 
abscess may cause necrotic processes in the vertebral column. Con- 
cussion of the vertebral column, produced from above, causes no 
increase of the pain in the acute form. 

In dipJitlieria swallowing pains are usually severe. Fre- 
quently, from the swelling of the velum, the taking of food be- 
comes difficult and painful, although in many cases no trouble of 
any sort is present. Generally there occurs a painful swelling of 
the submaxillary glands ; likewise, of the lymph glands lying 
under the sternomastoid muscle ; these frequently gi*ow into a 
large, very painful lump, especially sensitive to the touch. Here, 
one must not forget, in pharyngeal diphtheria, the pains arising 
(through the general infection) in the head, neck, back and the 
region of the buttocks, which often cause the patient very much 

The acuie infectious diseases, especially influenza, which 
causes very severe neck pain, with but little objective findings, 
are of interest. Escat has described such cases and has diagnosed 
them as pharyngodynia from influenza. Here one finds, at the 
most, a slight degree of erythema. This painful angina is closely 
related to the herpetic angina and disappears in the course of a 
few days. 

The febrile herpes of the pharynx, which is often associated 
with laryngeal herpes, appears very frequently in groups, occur- 


ring, also, in the form of small, diffuse, epidermic vesicles, and 
is especially characterized hj pain on swallowing. In a work 
given out from the Chiari Clinic of the Vienna University, Glas 
mentioned that frequently, after a short prodromal stage, severe 
difficulties of swallowing and sticking pains occurred in the throat, 
accompanied frequently by hoarseness and difficulties of breath- 
ing. The dysphagia often reaches such a pronounced degree that 
the patient is unable to take nourishment. Examination of 
the mesopharynx very frequently gives an entirely normal pic- 
ture. Laryngoscopic examination first shows on the base of the 
tongue, in the region of the follicular papillae, on the vault of the 
pharynx or on the pharyngeal wall, symmetrical vesicles. These 
are very prominent, varying in size from a poppy seed to a 
lentil, and are filled with white contents lying on a red base. 
These vesicles may be scattered, without any arrangement, or they 
may be gathered into groups. At this point it is time to emphasize 
(as we shall do later, in our description of chronic affections) the 
fact that one should always, in cases of pain on swallowing, ex- 
amine the region of the hypopharynx, where these efflorescences 
are likely to occur. 

As an example of these interesting infections, in which severe 
pain is always present, the following case is of note : 

"The patient, fifty years of age, felt, for a few days, weak 
and tired ; three days previous, chills and high-grade dysphagia. 
The patient gave the impression of being very ill, the head being 
held as it is in peritonitis gravis. The temperature was 38.9° C. 
(102.2° F.) and the pulse frequency was 110. The pharynx was 
perfectly free, and the tonsils were not in the least inflamed. 
The opening of the larynx (aditus) was greatly changed; the 
epiglottis, the aryepiglottic folds, the valliculse in the recessus 
pyriformis, were covered with vesicles of a somewhat similar size, 
not very prominent, and filled with gold-colored contents." 

Herpes zoster may, as I have frequently seen, give rise to 
very special pain in the region of the pharynx, which assumes a 
neuralgic character and reaches such an intensity that the other- 
wise fairly resistant patient whines and complains. Kaposi has 


described cases which correspond with the distribution of the 
maxillary nerve, the pains at the same time occurring in the 
cheeks, the palate and the pharyngeal mucous membrane of the 
affected area. The herpes arises sometimes as a diffuse, painful 
redness, sometimes as a group of efflorescences of a short duration, 
or even as gangrene of the rami palatini and pharyngei. 
Frequently with the signiiicant difficulties of swallowing severe 
toothache is present, with the resulting continuous neuralgi- 
form pains. I have seen two cases of herpes zoster associated 
with high-gTade dysphagia. In these cases only the mucous 
membrane of the mouth and pharynx was affected, and the efflor- 
escence was interrupted sharply in the median line. Cases 
have also been described in which it is almost impossible either 
to speak or to chew, each movement calling forth a tic dou- 

Herpes zoster is occasionally mistaken for acute pharyngeal 
affections. Here, also, phlegmonous inflammation of the base of 
the tongue is to be considered, for it very often occasions unbear- 
able pain, and, like peritonsillitis, makes deglutition impossible. 
The pains, which are severe, sometimes radiate to the ear. These 
diseases, because of the action of the inflammatory exudate on the 
giosso-pharyngeus, give rise to stimuli which are conducted back 
through the vagi, and are often associated with profuse salivation, 
high-gTade prostration, and difficulty of breathing. 

Pain in Chronic Diseases. — Among chronic diseases of the 
pharynx, which cause interesting pains, tuberculosis, lues, and 
malignant neoplasms of this region are prominent. 

Tuberculous ulcers of the pharynx produce severe pain, which 
is increased in swallowing. The pain frequently radiates to the 
ear, and the deeper the process extends the more severe it be- 
comes. The maximum is reached in tuberculous affections of 
the aditus laryngis, a very frequent disease. The ulcers located 
in the epipharynx, especially those having their location near the 
tuba of the ostium of the pharynx, are very painful, and, because 
of their location, are noteworthy, since for their diagnosis an 
exact posterior rhinoscopy is necessary (the unskilled rhinos- 


popist, in order not to overlook these diseased parts, should use 
a pharyngoscope). 

Swallowing, in cases of pharyngeal tuberculosis, is often very 
painful, and causes vomiting, which, in turn, aggravates the pain. 
Very frequently otherwise active anodynes, such as cocain, mor- 
phin, orthoform, etc., are entirely without effect, and the physi- 
cian finds it necessary to resort to morphin injections. For the 
severest laryngeal pain the alcohol anesthesia of the nerves is 
especially to be recommended. 

Luetic ulcers, at first, are not associated with very great pain, 
the superficial mucous membrane plaques causing only slight 
trouble; and attention should be called to the disparity between 
the extensive process and the slight trouble as characteristic of 
the first stage of syphilis. The first pain occurs on the deep exten- 
sion of the process, and may (for example, in deep, ulcerating 
gummata) reach a very high degree. Gummata of the base of the 
tongue and of the epipharynx, lying principally on the roof of the 
pharynx, may exist, in which the most prominent symptom is the 
excessive pain. Diffuse pain, radiating chiefly into the ear, 
accompanies this stage of the syphilitic process. It is also to be 
emphasized here that, with this group of symptoms, an exact 
retronasal examination should be made, and the region of the cir- 
cumvallate papillae carefully examined, because it is exactly here 
that the concealed seat of the affection is often to be found. 

In carcinoma of the base of the tongue there may be no pain in 
the early stages. The patient experiences only a scratching or a 
tickling in the neck. Often, upon pronounced movement of the 
tongue, he has the sensation as of a foreign body in the pharynx, 
and his complaint of this may lead to a false diagnosis. The deep 
extension of the carcinoma first produces severe, often signifi- 
cant pains radiating into the ear, the jaw, or the larynx. Pro- 
fessor von Bergman held the hemorrhage and pain which are pro- 
duced through the movement of the tongue, and through the con- 
tact of the hard food, as characteristic features of carcinoma of 
the tongue. He says: "They frequently are as pronounced as in 
the flat, tuberculous ulcers on the margin of the tongue. Fre- 


quentlj thej are neuralgic in character, and radiate toward the 
ear, and the nnhappy patients often complain fearfully" ("Hand- 
book of Surgery"). 

Of the group of chronic infections with which severe pain is 
associated pemyliigi of the mucosa are conspicuous. Often they 
suddenly burst open, or the vanishing vesicle, through hemorrhage 
of the submucosa, may occasion an increase of the ]3ain, especially 
in the efflorescence of the mucous membrane lying adjacent to the 
pemphigus follicle, which causes a diifuse epithelial desquamar 
tion, produces a high degTee of dysphagia, and, as a result of 
inanition, quickly incapacitates the patient. 

The isTEUKALGiAS OF THE PHAEYNX, which, without demonstrable 
organic changes, are found in hysterical individuals, are also to 
be considered. The patient often, for hours, will complain of 
lightning pains arising in the different parts of the mouth and 
radiating into the pharynx. Here, one should always seek for the 
pressure points, which are located in the region of the laryngeus 
superior glosso-pharyngeus or the lingualis. Those affections 
arising through tonic contraction of the swallowing muscles may 
be designated as hysterical dysphagia. In these strong pressure, 
accompanied by the closing of the teeth, produces a sticking or 
tearing pain. 


The sensory component of the vagus is the superior laryngeal 
nerve, which, arising from the vagus, runs median to the internal 
carotid as far as the thyrohyoid ligament. At the upper half of 
the greater cornu of the hyoid bone the nerve divides into an 
outer and an inner branch, of which the outer has motor and the 
inner sensory fibers. The latter passes through the thyrohyoid 
ligament and reaches the recessus jDyriformis, where it supplies the 
mucous membrane covering the plica of the laryngeal nerve, and 
ends in the mucous membrane of the lar^Tix. At the same time it 
forms an anastomosis with the laryngeus inferior, and concerns 
itself with the delivery of sensory nerve fibers to the recurrens. 
At this point, the observation made by Massei, of anesthesia of 


the laryngeal entrance in recurrens paralysis, may be cited. 
This he gives as a reason for his opinion that the recurrens really 
conducts sensory fibers. My examinations, following those of 
Massei, do not confirm his observation, so that I, as the result of 
an enormous amount of clinical^.experience, and because of other 
reasons, have reached the conclusion that the recurrens has nothing 
whatever to do with the sensibility of the larynx. 

Referred Pain. — Diseases of the larynx generally produce no 
referred pain nor tenderness, but when pain does exist, it is gener- 
ally felt in either the suj^erior or inferior laryngeal area, the 
upper area being particularly associated with disease of the epi- 
glottis and aryteno-epiglottidean folds, the lower area being par- 
ticularly associated with disease of the cords (Head). 

Pain in Acute Affections'; — Laryngeal pain may be found in 
all acute inflammations, chiefly in those associated with pus for- 
mation. Here the intensity of the pain depends especially upon 
the location of the process. The aditus laryngis, that is, the 
epiglottis, aryepigiottideati folds in the arytone, is the region in 
which inflammation produces the most severe pain. It depends, 
on the one hand, upon the richness of the sensory nerves in this 
region, and, on the other hand, upon its relation to the process 
of swallowing. The bolus, gliding over the aditus, irritates the 
inflamed area and produces, at the same time, an increased reac- 
tion as well as pressure pain. A clear proof of the increased pain 
sensibility in involvement of the aditus is found in acute affec- 
tions ; for example, in herpes laryngis, involvements of the ary- 
epiglottidean folds and the recurrens pyriformis are so painful 
that swallowing becomes impossible. Here the pain frequently 
radiates into the region of the base of the tongue and the middle 
auricular nerve of the vagus irtithe ear zone. On the side of the 
larynx a clearly defined ulcer may frequently be present for a long 
time without causing severe pain, because swallowing is not dis- 
turbed. Here, upon manifestations of pain in these parts, I again 
suggest a minute examination of the entrance of the larynx, espe- 
cially of the recessus pyriformis, in order to avoid the overlooking 
of a diseased process. 


Chronic Processes. — Under the chronic processes are, again, 
the tuberculous ulcers, as well as the crumbling carcinoma (extra- 
laryngeal), which may give rise to an intense, often unbearable, 
pain. The dysphagia of a patient suffering from a diffuse laryn- 
geal tuberculosis often reaches such a high degTee that he will 
refuse to take food. The blowing in of orthoform, the instillation 
of menthol, the insufflation of morphin, dysphagia tablets, paint- 
ing with cocain, etc., very frequently fail, in the ulcerative form 
of laryngeal tuberculosis, to relieve the pain, so that in a short 
time after the onset of this affection one can do nothing for the 

The anesthesia of the entrance to the larynx, by Hoffman, 
through injection of alcohol in the superior laryngeal nerve, at 
its place of entrance through the thyrohyoid ligament, has given 
a very satisfactory result in many cases, in that the dysphagia 
diminishes and the otherwise rapid inanition is hindered. I can, 
upon the basis of a large number of injections made in very sick 
tuberculous patients, warmly recommend this treatment, and I 
would like to emphasize the fact that, in a number of cases, I was 
able to induce an anesthesia persisting through many weeks. 

The pain in carcinoma of the larynx depends upon the locali- 
zation of the tumor. Extralaryngeal tumors, lying in the region 
of the aditus, give rise very early to pain on swallowing, while in 
intralaryngeal tumors pain may not appear for a long time. 
There are, then, because of the overgrowth of the tumor, severe 
disturbances of swallowing. One may say, in regard to the early 
diagnosis of carcinoma of the larynx, that the first symptom of the 
extralaryngeal carcinoma is, as a rule, dysphagia and that the first 
symptom of intralaryngeal carcinoma is hoarseness. Yet there 
are cases, to which Leopold von ^chroetter, especially, has drawn 
attention, where, in spite of severe destruction in the region of the 
aditus, pains are entirely absent. However, these are very rare. 
The explanation lies in the fact that in these cases there are sen- 
sory disturbances in the area of distribution of the superior laryn- 
geal nerve. Generally the pains are spontaneous, on deglutition 
as well as upon external j^ressure. The pain in carcinoma of the 


larynx is explained through the simultaneous occurrence of in- 
flammatory conditions, necrosis formation, and hardening, while 
the pressure symptoms, or the propagation of the irritability, 
occur from the involvement of the superior laryngeal nerve. Often 
the pains assume the form of neuralgia, and radiate as lightning 
pains into the region of the nervus auricularis vagi. 

Laryngeal neuralgia is infrequent, and is observed in hys- 
terical and neurasthenic subjects. The neuralgia often radiates 
to the ear and frequently reaches an unbearable severity. Lemon 
has reported a case in which a patient, in the climacteric period, 
threatened suicide if freedom from her raging pain was not 
obtained for her. In other patients, when the pain occurs on 
speaking, it shows itself as a typical phonophobia. Finally, it is 
mentioned that, in these glottis spasms which we so frequently 
find in tabes dorsalis, the so-called laryngeal crises, hyperesthesia 
and hyperalgesia, in the form of sensory aurae, are often found, 
and introduce the cramp crises. The explanation of these forms 
of pain is probably analogous to that of the adduction spasm, they 
being due to an irritation of the sensory sphere. The typical 
attack in such cases occurs as a peculiar sensation in the larynx, 
in the form of a sticking, burning, lightning pain, accompanied 
by states of anxiety or feelings of suffocation, after which the 
spasm of the glottis follows. 



Classification. — There are two classes of abdominal pain : sub- 
jective and objective. 

The subjective pains belong to the class of symptoms usually 
termed hysterical. For their production no organic basis can be 
found. They seem to be due to the awakening into consciousness 
of sensation-phenomena stored away in the subconscious mind. 

Objective pains, on the other hand, have for their produc- 
tion either some definite pathologic change, functional or or- 
ganic, or a changed relationship of the organs as a whole to other 
adjacent organs, such as occurs, for example, in a ptosis of the 
stomach or of the liver. 

Subjective pain, in relation to the abdominal viscera, will 
not be considered here. It has already been discussed in the 
opening chapters. 

Objective abdominal pain is important because of its rela- 
tionship to changed pathology in the abdomen. It may be due to 
a lesion of the skin, the subcutaneous tissues, the muscle, the peri- 
toneum, or the viscera. 

The SKi?v" is frequently painful, especially when it is the seat 
of some inflammatory skin-disease, such as erysipelas. It is also 
very painful in certain nerve lesions, as neuritis, or herpes. 


by Mackenzie with pain production. He says : "It is the 
muscular layer in the abdominal wall which is so exquisitely ten- 
der in all affections of the viscera, giving rise to severe reflex 
musculovisceral pain, as in appendicitis. Also, the abdominal 


muscles above the lesion are in a state of contraction and are 
extremely tender to pressure." That Mackenzie erred and exag- 
gerated the importance of the muscular coat in pain production is 
proved by the researches of Lennander and others. Later, Mac- 
kenzie (862) himself, modifying his previous statements, says 
that the subperitoneal layer is the most sensitive, and, in confirma- 
tion of his views, quotes Ranstrom, who has found many nerves 
and nerve endings in this layer. The nerves are derived from 
those supplying the muscular layer. All direct painful muscular 
lesions in the abdominal wall are the result of inflammation, 
neuritis, neuralgia, myalgia, or new gTowths. 

Inflammation in the ahdominal wall is accompanied by all 
the signs and symptoms usually associated with inflammation in 
general, such as swelling, redness, heat, and loss of function. The 
pain is of a throbbing character. Tenderness on pressure is also 
present. In some cases the inflammation precedes abscess forma- 
tion. Such cases are described by Hitzrot (337). The pain was 
localized, and was increased on assuming the erect posture and on 
deep pressure. He quotes Fouquet (370), Sonnenberg (371), 
Spellisy (372), Heller (373) and Allison (374), who have all 
described similar conditions. 

Neuralgia of the nerves of the abdominal wall occurs and is 
frequently observed with or after infectious diseases. When it is 
present the skin is exquisitely tender, and is very painful to the 
pressure made by pinching it between the fingers. In this it dif- 
fers from peritonitis, in which the skin is not so tender, and the 
pain is produced only on deep pressure. In neuritic lesions of 
the abdominal walls the pain is usually unilateral. When the 
lumbar nerves are afi^ected, the pain is commonly felt in the 
hypogastric region, a little to one side of the median line. In 
this area, too, there is localized tenderness on pressure. Tender 
spots are also found, one a little to the outside of the first or 
second lumbar vertebra, and another immediately above the crest 
of the ilium. In women, who are by far the greatest sufferers 
from this disease, there is also sometimes, about the middle of 
the Fallopian tube, a spot, pressure upon which causes pain to 


be referred to the anterior abdominal wall. There is another 
spot above the uterus. In men, points here and there on the scro- 
tum are found which are painful to the touch. These points of 
tenderness serve as characteristic signs of neuralgia. ITeuralgia 
is to be diagnosed, not only from colic, but from lumbago and 
rheumatism of the abdominal walls. Diagnostic signs of neu- 
ralgia are the absence of fever and the relief which is produced 
by pressure and ordinary antineuralgic remedies. 

Neuritis of the intercostal nerves is fairly frequent. This 
frequency occurs because these nerves are particularly subject to 
the deleterious influences of cold and traumatism, on account of 
their exposed position. (For a more complete description see 
under JSTeuritis.) 

Myalgia is closely related, as far as etiology is concerned, to 
the neuralgias. It seems to be due in very many cases to a dis- 
ordered metabolism. This is the condition to which the term 
"rheumatism of the abdominal wall" is given wrongly. 

New growths, such as cysts and various kinds of tumors, may 
occur in the abdominal wall. If of slow development, they cause 
no great inconvenience, for by their slow increase in size they 
gradually push the surrounding structures to one side, and the 
tissues learn to accommodate themselves to the presence of the 
foreign occupant. Should nerves be incorporated in the growth, 
and pressure be exerted upon them, pain, generally of an aching 
character, results. This pain may be localized to the region of 
the growth, or may be referred to some distance in an area to 
which the affected nerve is distributed. The size of the growth 
bears no relationship to the amount of pain which it may pro- 
duce, the smaller growths producing as much, if not more, pain 
than many of the larger ones. The amount of the pain depends 
upon the rapidity of the growth, the number of nerves incorpo- 
rated in it, and the pressure exerted upon them by the inclosing 

Pekitoneum. — According to Mackenzie, the peritoneum of 
itself is devoid of pain nerves. However, he claims that the sub- 
peritoneal layer is plentifully supplied with pain nerves, and that 


it is here that the painful impulses arise. In its lack of pain 
perception, the peritoneum, he says, is not unique among serous 
membranes, for this is characteristic, he holds, of all serous mem- 
branes, since they have no nerves which vv^ill transmit pain stimuli 
of the kind found in the skin, the tunica vaginalis testis being the 
only serous membrane which is sensitive to the usual tests for 
pain sensibility. This is due to the fact that the tunica vaginalis 
testis is innervated by a cerebrospinal nerve, the genital branch of 
the genitocrural nerve. 

Mackenzie's proofs that serous membranes are not the seat of 
pain production were : (1) that the abdominal wall is very tender 
in certain visceral colics in which there is no inflammation of the 
peritoneum; (2) the skin of the abdominal wall generally is not 
so sensitive in visceral lesions, for it can be pinched between the 
fingers without producing pain; but if the muscles are grasped 
between the thumb and fingers, acute pain is felt; (3) direct 
stimulation of exposed pleura, pericardium, and peritoneum does 
not produce pain. That this is not absolutely true will be shown 
in the discussion of peritonitis. 

The peritoneum is the lining membrane of the abdominal 
cavity. It consists of two layers: (1) the visceral layer, which 
covers the inclosed organs, and (2) the parietal, which lines the 
external wall of the cavity. It has been held by many that the 
visceral peritoneum is without pain sensibility, but, as will be 
pointed out, much depends upon the type of stimulus. The adequate 
stimulus in the viscera is deep pressure; that largely produced 
by tension. It is the type of deep sensibility described by Head. 

It was the belief of Lennander that "all painful sensations 
within the abdominal cavity are transmitted only by means of 
the parietal peritoneum and its subserous layer, both of which 
are richly supplied with cerebrospinal nerves around the whole 
of the abdominal cavity, with the exception of a small area in 
front of the vertebral column lying below the crura of the dia- 
phragm, and between the two chains of sympathetic nerves." 
Here he found no cerebrospinal nerves, but only nerves running 
more or less transversely between the two sympathetic chains. 


He found that within this area the patient does not respond to 
hard pressure with a finger, or with an instrument, and that 
stretching of the mesenteric attachments at this point is not pain- 
fuL So far complete uniformity does not exist as to presence or 
absence of pain sensibility in the peritoneum, though many ob- 
servers are in accord with the deductions of Lennander. 

Diseases of the peritoneum producing pain are inflammations, 
hemorrhage, and new growths. 

Inflammations of the Peritoneum.— Inflammation of the peri- 
toneum (peritonitis) causes pain only when acute. The chronic 
inflammatory forms, as a rule, produce but little pain, except 
as the result of adhesion formation. The seat of the pain in peri- 
tonitis, according to Mackenzie,^ is not in the peritoneum itself, 
but in the subperitoneal tissue. This layer is exquisitely tender, 
and Kamstrom found it richly supplied with nerve fibers, which, 
in turn, are derived from the nerves of the anterior abdominal 
wall. These nerves also supply the abdominal muscles, and thus 
one can account directly for the reflex rigidity of these muscles 
(supplied by the same nerves) when the peritoneum is affected. 

In some cases, however, acute peritonitis may be present with- 
out producing any pain phenomena. This is especially so in the 
violent cases in which the abdomen contains a quantity of pus 
(Bradford, 207). This lack of pain may be due to the rapid 
destruction of the nerve endings, or to the impairment of their 
efficiency. Such a state is frequently met with in puerperal 

However, in all cases of sudden, sharp, exacerbating pain, 
with rigidity of the abdominal muscles, generalized tenderness, 
normal or subnormal temperature, and a rapid, rising pulse, peri- 
tonitis should be thoughtfully considered (Kichardson, 23). 
Should the pain be dull and aching, the sub-peritoneal connective 
tissue is probably involved. 

1 It is also claimed by Mackenzie that the parietal peritoneum or rtsexi 
is insensitive to pain; that it is the tiny nerve filaments, distributed in the 
cellular tissue subjacent to the peritoneum, which are extremely sensitive, 
and that the slightest traction or pressure on them produces the most ex- 
cruciating pain. 


TuBEECULOus Peeitonitis. — In cases of tuberculous origin 
pain may be an almost negligible symptom. The exceptions are 
those conditions in which adhesions have developed, or in which 
the tuberculous material has become encysted and has ulcerated 
or suppurated. This gives rise only to a little pain on walking, 
while obliterative, encysted, or sciatic forms may cause no pain 
(Rolleston, 619). In case of tuberculous peritonitis Bainbridge 
has found that the injection of oxygen into the peritoneal cavity 
will relieve the pain. This may be due to the separation of the 
two adjacent surfaces from each other, possibly to an anesthetic 
action of the oxygen. 

A common source of mistakes in the diagnosis of peritonitis 
is the confusion of referred pain with that due to peritonitis. 
Diagnostic criteria between the two conditions are: (1) The ten- 
derness of referred pain is produced by slight stimulation of the 
skin and the subcutaneous tissues, and seems to be relieved by 
deep pressure; (2) the exact opposite is found to be the case in 
peritonitis, deep pressure being painful, while light pressure is 
not so distasteful; according to Lennander (618), the boundaries 
of the hyperesthetic zones in peritonitis can be mapped out 
almost to a centimeter; (3) in peritonitis proper there is gener- 
ally no referred pain; this is given by Moullin (226) as a good 
indication that no other viscera are involved, for as soon as the 
viscera become involved hyperalgesia is present; (4) in perito- 
nitis the abdominal reflexes are not exaggerated, while in referred 
pain they are exaggerated. 

Should a peritonitis be sudden in onset, as is the case in the 
perforation of an ulcer of the stomach, or of the duodenum, the 
pain is generally paroxysmal and is most severe. When the car- 
diac end of the stomach is involved, the pain, as a rule, is under 
the left scapula. When the pyloric end is the part affected, the 
pain is under the right scapula (Mayo Robson, 619). 

If the abdominal pain is associated with tenderness it is neces- 
sary to distinguish between inflammaticui of the constituents of 
the wall (skin, muscle, peritoneum), neuralgia and neuritis. In 
peritonitis pain is ])rodu{'ed only on the making of ]jressure on the 


abdominal wall, while in neuralgia or mvalgia it may be necessary 
to pinch the skin or mnscle l^etween the fingers before pain is 
elicited. If peritonitis is present there is also pain on the patient 
taking a deep breath, upon the making of a pelvic examination, 
and also, in some cases, npon flexion of the body. Should the pel- 
vic peritoneum be inflamed, pain is produced when the inflamed 
jDeritoneum is pressed upon by the examining finger. Tilting up 
of the uterus by pressure on the cervix will always cause pain, 
and pain is also present on. making deep, and, if the peritonitis 
is severe, light pressure low down on the abdominal wall. Biman- 
ual externovaginal examination will cause pain if the peritoneum 
at the brim of the pelvis is inflamed. Defecation, micturition and 
sexual connection (if a female) are also painful. The visceral 
peritoneum is different from the parietal peritoneum in that pain 
is not produced by pressure upon it ; but it is very sensitive to 
traction made upon it through the mesentery. The pain produced 
by this traction is interpreted as coming from some zone of the 
body and not from the affected viscera. This Mackenzie ex- 
plained by the fact that the abdominal viscera are supplied en- 
tirely by the sympathetic system, which has no sensory nerves. 
When it is irritated its nerves carry impulses to the cord cells and 
stimulate, in turn, adjacent sensory cells to activity, thus caus- 
ing a painful impulse to be conveyed to the brain. This impulse 
is projected as if coming from the peripheral distribution, areas 
of the sensory nerves, whose cells are stimulated. 

Cheoxic peritonitis is somewhat different from the acute, 
and is much slower in onset and duration. The pain is due to 
the following causes : 

(1) Traction and j^ull from adhesions, the result of the 
chronic inflammatory process. 

(2) Distention of the bowel from gas or fecal matter, owing 
to obstruction of the lumen by adhesions which may be old or 

(3) Localized collections of fluid encysted by the peritoneal 
adhesions. These localized collections may be either serum, pus, 
or blood. After the fluid contents have reached a certain stage, 

s, Perforative 



CoPnset. Continu- 
tiojTed to lower ab- 



Pain resembles that of 
childbirth. Comes on at 
intervals, and is associated 
with uterine hemorrhage. 


Fr«s an early symp- 

No vomiting as a rule. 





/ery rapid. Typ- 
L and thready. 

Pulse may be sUghtly in- 
creased. In some cases, 
owing to fright and exces- 
sive loss of blood, it may be 
very rapid. 



to « 






Tumor mass is absent. 


Of appendiceal in- 
thei- Intestinal in- 
tioii; typhoid, tu- 

History of pregnancy. 


No a rule, is not so 
ock with a low 
re may at first be 






Heisis. Hemoglobin 
Re«lls normal. 

In cases of great loss of 
blood hemoglobin, reds and 
whites may be all decreased. 
In other cases no marked 












may or may not 
. Mass absent, 

Fluid absent. Mass (en- 
larged uterus) can often be 
demonstrated. No abdom- 
inal rigidity. Peristalsis 





Peritonitis, Perforative 



Comes on generally after exer- 
tion, and is sudden in onset. The 
pain is most intense and is local- 
ized in the lower abdomen. In 
some cases a pain is also felt in 
the shoulder of the same side. 

Pain may be gradual in onset, 
though in some cases it is very 
acute. Begins in the lower part 
of abdomen. In acute cases the 
pain is sudden in onset and is local- 
ized in the tubal areas. In general- 
ized peritonitis pain is absent. 

Generally sudden in onset. At 
first is in the midline. Later it 
passes over to the right iliac fossa. 

Sudden in onset. Continu- 
ous. Referred to lower ab- 

Pain resembles that of 
childbu-th. Comes on at 
intervals, and is associated 
with uterine hemorrhage. 


Frequent and synchronous with 
the pain. 

Vomiting is a late symptom. 

Vomiting is an early symptom. 

Vomiting is an early symp- 

No vomiting as a rule. 


At first, because of shock, may 
not be greatly increased in rapid- 
ity. After the primary shock, 
the rapidity is not very great until 
the arnount of blood lost becomes 

Generally rapid in acute lesions. 
In chronic lesions generally no 

Generally very rapid in acute 

Generally very rapid. Typ- 
ically small and thready. 

Pulse may be shghtly in- 
creased. In some cases, 
owing to fright and exces- 
sive loss of blood, it may be 
very rapid. 


Very sensitive and tender and lies 
to one side of the uterus. Is con- 
stantly increasing in size. After 
rupture, when a hematocele has 
formed, the tumor mass of the 
uterus rapidly increa-ses in size, 
and is soft and boggy. 

Painful swelling to one side of the 
uterus. Generally the uterus is 
fixed and is not freely movable. 
Tumor is often bilateral. 

Tumor in acute appendicitis can 
rarely be defined because of the 
excessive tenderness and rigidny 
of the abdominal muscles. Per- 
cussion sometimes elicits tender- 
ness when palpation fails to do so. 
If an abscess has formed, it can 
be felt by vaginal examination. 

Tumor absent. 

Tumor mass is absent. 


Of pregnancy, with enlargement of 
the uterus which is not in propor- 
tion to the stage of the pregnancy. 

History of recent childbirth or of 
a vaginal infection. Often no 
accountable cause is present. 

History of a previous attack may 
be present. 

History of appendiceal in- 
flammation. Intestinal in- 
flammation; typhoid, tu- 

History of pregnancy. 


No elevation. Generally normal. 

Rise of temperature. 

Generally sudden, progressive rise. 

At first, as a rule, is not so 
high. Shock with a low 
temperature may at first be 




Not enlarged. 

Not enlarged. 

Not enlarged. 



Hemoglobin low and decreasing. 
Red and white cells both reduced. 

Hemoglobin high; whites in- 
creased; reds normal. 

Leukocytosis. Hemoglobin and 
red celk normal. 

Leukocytosis. Hemoglobin 
and red cells normal. 

In cases of great loss of 
blood hemoglobin, reds and 
whites may be all decreased. 
In other cases no marked 


Fluid, if the hemorrhage has been 
very great, may be elicited on pal- 
pation and percussion. Puncture 
of the posterior vaginal vault with 
an aspirating needle frequently 
will at once reveal condition. A 
mass is present in pelvis. Rigid- 
ity of abdominal muscles may be 
present. No change in intestinal 

No fluid, but a mass connected 
with the uterus may be felt in the 
pelvis. Rigidity of the lowest 
segm.ent of the rectus. No change 
in intestinal peristalsis. 

No fluid present. Mass in right 
iliac region may be felt when 
abscess has formed. No change in 
peristalsis. Localized rigidity over 
lower segment of rectus. 

Free fluid may or may not 
be present . Mass absent. 
Peristalsis diminished. 

Fluid absent. Mass (en- 
larged uterus) can often be 
demonstrated. No abdom- 
inal rigidity. Peristalsis 


they begin to exert pressure or traction on the adjacent structures, 
and thus cause the pain. In some cases of slow, insidious peri- 
tonitis, especially those of tuberculous origin, there may be no 
pain of any moment until adhesions form, when pressure causes 
tension pains. 

The location of the pain may give an indication of the viscera 
which are involved by the adhesions (for the points of reference 
on the abdominal wall of visceral pain, see Viscera, Chapter XX, 
pp. 383-389). 

Hemorrhage. — In sudden, severe hemorrhage into the abdomi- 
nal cavity, such as occurs in the rupture of an extrauterine preg- 
nancy, pain is present ; but in hemorrhages following operation, 
pain, as a rule, is absent. This latter condition can probably be 
accounted for by the previous insult to the peritoneum by the 
operative procedures, with the consequent reduction in its sensi- 

In some cases of excessive dilatation of the abdomen from 
tympanites, or from obstruction, the abdominal tenderness is ex- 
cessive, but at the same time the pulse and temperature are not 
of a peritoneal character. 

Tumors of the Peritoneum. — Tumors of the peritoneum gener- 
ally cause pain. When they are in the back, and lie posterior to 
the peritoneum, they frequently cause pain by the pressure which 
they exert upon the spinal nerves. This pain is referred to the 
back or along the course of the nerves of the lumbosacral plexus. » 
It must be diagnosed from the pains due to aneurysm, vertebral 
caries, or spinal tumor. 

Nature of Pain from Adhesions. — As an end result of nearly 
all processes, both inflammatory and otherwise, in the abdominal 
cavity, is adhesion formation. These adhesions, as a rule, cause 
pain, which is generally localized to one spot, at which point pain 
is also produced by pressure. 

The pain may come in paroxysms ; when it does so, the 
attacks resemble each other, and have the same train of symptoms. 
The pain also is influenced by certain muscular movements or 
positions of the body, and may be lessened or increased by mov- 


ing about or by turning' over from one side to the other. It is 
increased bj peristalsis, especially if the adhesions are between the 
stomach or intestine and the anterior abdominal wall. When the 
adhesions are between the stomach and the anterior abdominal 
wall, the pain is often increased after eating. Adhesion pain 
is also increased by tension of the anterior abdominal wall, when, 
by a backward motion of the upper part of the body, or hyper- 
extension of the thigh, the distance between the ribs and the pelvic 
bones becomes increased. In such cases the recti muscles become 
rigid and traction is made on the adhesions. The magnitude of 
the jDain varies indirectly as the area of the adhesion. This is 
due to the fact that, in extensive adhesions, the traction upon the 
parietal peritoneum is not limited to any one spot, as it is in 
very limited adhesions, but is sjDread out over a large area, and 
consequently, not being perceived acutely in any single nerve 
distribution, is felt rather as a dull, dragging pain, instead of a 
sharp, pulling one. 

Increased tension of the anterior abdominal wall also causes 
pain in cases of hernia wherein stretching of the omentum is 
probably present. 

Adhesions pulling upon the peritoneum, as a rule, cause 
greater pain if there is a sudden variation in the traction, such 
as can occur when a hollow viscus of changing size and position, 
such as the stomach, is attached to the anterior abdominal wall. 
In this case the pain depends uj^on the variations in the force of 
the traction, depending upon the amount of the stomach contents 
and the state of its functional activity. 

Adhesions of the omentum and the anterior abdominal wall 
are a frequent cause of pain, because the bowel places the omen- 
tum on the stretch, by forcing itself into the pocket between it 
and the anterior abdominal wall. Adhesions between the viscera 
if not connected with the anterior abdominal wall cause no 
pain unless traction or pressure is made upon the mesentery or 
other pain sensitive organs, by the changing relationships or the 
hindered movements of the adherent viscera. 

In this connection it might be well to consider the causes of 


abdominal adhesions. They are the following: (1) tumors, which 
form adhesions because of the j)ressure on, and consequent trau- 
matism of, adjacent organs; (2) intestinal ulceration, which is 
not an active cause of adhesion formation unless perforation has 
occurred; (3) after laparotomies adhesion between the omentum 
and parietal peritoneum; and (4) inflammation, particularly that 
due to or associated w'ith tuberculosis. Inflammatory lesions of 
the gall-bladder are also potent causes of abdominal adhesion for- 

Abdominal adhesions, according to Cumston, are divided into: 

(1) A gastric gToup, including cholelithiasis; ulcer of the stom- 
ach and duodenum; traumatism to the stomach, liver, pancreas, 
and duodenum ; carcinoma of any of the above-mentioned organs ; 

(2) the intestinal gi'oup, which is particularly associated with 
the appendix and the sigmoid; (3) the pelvic group, which in- 
cludes lesions of the tubes, ovaries, and the uterus; and (4) the 
peritoneal group, including all lesions in which primarily the 
peritoneum is involved, as in tuberculous peritonitis. 

Gastric Adhesions. — The diagnosis of adhesions may be made 
easier if it is borne in mind that ^vhen adhesion of a viscus to 
the anterior abdominal w^all or to another organ occurs, pressure 
or traction on the abdominal w^all, so made that it wall tend to 
separate the two adhering surfaces, will produce considerable pain. 
Thus, in gastric adhesions, if pressure is made on the anterior 
abdominal wall in an upward direction, ^from the region of the 
lower border of the stomach, the pain wdiich is present on ordinary 
manipulations is greatly increased. If the adhesions are on the 
right or on the anterior border of the stomach, pressure made over 
the epigastrium will cause the pain to shoot out from the right 
over the area of the adhesions. If they are on the posterior gastric 
wall, pressure over the first and second lumbar vertebrae will often 
cause pain. Adhesions betw^een the anterior abdominal w^all and 
stomach are not so frequent, and are very apt to be confused with 
gastric ulcer. Pain due to intestinal adhesions, as a rule, is sud- 
den and acute, and is the result of stenosis of the gut by the ad- 
hesions ; generally it is of short duration, disappears as quickly 


as it came, and is frequently followed by a discliarge of fluid feces 
or flatus. 

Intestinal Adhesions. — An interesting case of intestinal adhe- 
sions is tliat of a young lady, whose history is as follows : 

ISTearly two years before admission to the hospital she began 
having acute pains in the abdomen, of a spasmodic character. 
During the past year these have become more frequent and are ac- 
companied by vomiting and eructations of gas. The attacks 
seem to be brought about by eating indigestible foods and exposure 
to colds and dampness. She has had two attacks at night without 
apparent cause. The menses are painless. The pains are always 
relieved by a bowel movement. At first they are diffused over the 
abdomen, but soon show a distinct right-sidedness. During the 
last attack the pain was mostly toward the median line, slightly 
to the right. 

Operation showed the cecum and adjacent intestinal coils all 
matted together by dense adhesions, which, in some places, were 
so thick that they had to be cut between ligatures. A tumor, cor- 
responding in location to this mass, was felt on the right side 
before operation. 

Pelvic Adhesions. — Pain due to pelvic adhesions is present 
(a) at stool, (b) during micturition, (c) during the menses, (d) 
on moving, (e) on subjecting the body to light shock, and (f) dur- 
ing coitus. 

A case in point is that of Mrs. X , whose ovary and tube 

on the right side, and appendix were removed, drainage being in- 
serted because of the pronounced gangrenous state of the appendix. 
Some weeks after operation she complained of aching which was 
worse after moving, after lying down at night, and on sweeping. 
This aching begins in the lower right middle region anteriorly and 
extends through to the back in the lumbar region. 

Another case is that of Mrs. Y , in whom pain began in 

the right side and was constant. She had a feeling as though a 
knot were being tied inside her. On the same side a small mass 
was present. A year previous she had had an operation per- 
formed, in which the ovaries were removed. In this case there 


was present a band of adhesion, extending from the uterus, its 
appendages, and the intestines, to tlie lateral pelvic wall. 

General Peritoneal Adhesions. — If the pain is due to general- 
ized peritoneal adhesions, for instance those following a gastric 
perforation, it is often present after eating, and comes on when 
the stomach is full or when the patient assumes certain positions. 
Pritchard (620) reported a case of abdominal pain, in which 
the diagnosis was obscure, but on operation adhesions were found 
between the stomach and the anterior abdominal wall. Xo previ- 
ous symptoms indicating inflammation could be elicited ; no ulcer- 
ated areas, nor indications of ulcer, could be found. After re- 
viewing the case and excluding the gall-bladder, stomach, or duo- 
denal ulcers as the cause of the adhesive formation, Pritchard, 
because of the presence of an edema of the lower extremities, 
without sufficient cause in the same patient a year or two previ- 
ously, offered the novel explanation that the edema was due to ■ 
neurotic influences, and that the abdominal adhesions were the 
result of the same influences acting in the abdominal cavity so as 
to produce edema of the stomach and duodenum, and consequent 
adhesive formation. 

Nature of Pain in Hernia. — Because of the mechanical rela- 
tionship of hernia to the abdominal structures, it has been thought 
wise to consider it in this section. Pain is not a prominent 
symptom of simple uncomplicated hernia, except in those cases 
wherein the hernia is of sudden development. Here the pain is 
due to: (1) Traction on the mesentery. This occurs in the 
early stages of the condition. Later the pain is due to: (2) In- 
flammation of the bowel, which is the result of deficient circula- 
tion, edema, and the presence of toxins. This inflammatory 
process causes the contents of the hernial sac to swell, and, if the 
neck is small, the hernia becomes strangulated, and the traction 
and pull upon the involved mesentery are increased. The inflam- 
matory process may also extend to the parietal peritoneum, and 
to the pain of the traction there is also then added the pain of 
the peritoneal irritation. (3) Peritoneal irritation. The inflam- 
mation may progTess to such an extent that adhesions finally form 


between the peritoneum and the bowel, and then every movement 
may be capable of producing pain of a dull, dragging character. 
Thus pain of hernia may be due to involvement of the mesentery, 
the bowel, or the peritoneum. 

The mesentery as a factor in the pain production is generally 
of little moment unless the onset of the hernia is sudden, when 
there is present, in the majority of cases, a severe, draggi'ng pain, 
most frequently about or above the umbilicus, if the hernia is of 
the small intestine ; while if it is of the lower bowel, the pain or 
distress is generally below this level. The mesentery probably 
also receives a few fibers from the cerebrospinal system; and, 
when irritation to them occurs, the resulting pain is generally 
referred to their somatic distribution. When this is the case, the 
area of tenderness and of subjective pain is generally outlined by 
the area of distribution of one or more of the spinal nerves. 

The ilioinguinal nerve passes out of the abdomen at the exter- 
nal abdominal ring, and is distributed to the ilioinguinal region 
of the upper and inner part of the thigh to the scrotum in the 
male, and to the labium in the female ; hernia, producing pressure 
on this nerve, causes pain to be felt as coming from these parts. 

Bowel pain jDroper differs from that of hernia, in that the pain 
sensation is due to the carrying of stimuli to the cord, where some 
of the cells of the spinal nerves, being stimulated, give rise to 
pain sensation, which the brain interprets as coming from the 
peripheral distribution of these fibers. The area of tenderness 
and subjective pain felt in the distribution areas of these fibers 
does not follow the plan of distribution of any spinal nerve or 
nerves, but is located in the area of distribution of fibers arising, 
from certain cord segments, as marked out by Head. The points 
of tenderness, which, in many cases, bear no definite relation to the 
lesion causing the trouble, are but the maximal points of tender- 
ness of these cord segments. If the hernia is in the small intes- 
tine, the most common site of the referred pain is in the region 
of the umbilicus, while in involvement of the large bowel the pain 
is located as being below this point; if peritoneal irritation is 
present, a local tenderness is felt at the place of the lesion. A 


part at least of this bowel pain is due to distention of the involved 
portion of the bowel bj gas. When this factor is present, the 
pains are generally paroxysmal, occurring at the time of the 
bowel distention, and are eased as soon as the gas and the fecal 
contents have passed on ; but should the swelling at the neck of 
the sac increase, the hernia then becomes strangulated, and to 
the other factors producing pain is then added a third, namely, 
peritoneal irritation. 

In ijeritoneal irritation the pain at first is slight, and similar 
to that described above; but after it once develops, it is so much 
more severe than the other two that they are of minor importance. 
The tissues are now exquisitely tender, and are sensitive to the 
slightest pressure. It is at this stage that, in case of femoral or 
inguinal hernias, the patient instinctively draws up and rotates 
inward the leg of the affected side. 

The omental hernias are generally not very painful, because 
the omentum, of itself, has little pain sensibility; but, in some 
instances, as in a case of ventral hernia, where the patient had 
suffered from cramps and severe abdominal distress, with vomit- 
ing, an operation showed a small omental ventral hernia about 
two and one-half inches above the navel and a little to the left of 
the median line. There was no localized tenderness. 

Pain, as a sym^Dtom of simple uncomplicated hernise, is gener- 
ally of minor importance. Few of the cases of hernia are acute 
in their onset, most of them being the gradual development of 
years ; and even when the hernia is acute, the pain symptoms are 
not of special diagnostic importance, only in so far as they indi- 
cate the special region of the bowel attacked, and the magnitude 
of the involvement. In chronic cases there may be a smarting 
or burning, which De Garmo thinks most likely indicates an 
omental protrusion. The most common pain is of a dragging 
nature, and is worse in the evening and better in the morning, 
because during the night the intraabdominal pressure is relieved.^ 

* Sir William Bennett {Lancet, Feb. 2, 1907, p. 270) mentions a case in 
which the hernial sac had a very small opening; and he suggests that it was 
due to the accumulation of fluid in the sac, as the day went on, which caused 
the pain to be so much more pronounced toward evening. 


Anything causing a rise of the intraabdominal pressure, such as 
coughing, sneezing, straining, or lifting, is likely to produce this pain. 

Strangulated hernia generally gives rise to the greatest dis- 
tress, very often present around the umbilicus, and when this is 
associated with vomiting the diagnosis of gall-stone colic or gas- 
tritis is very apt to be made, and the hernial condition neglected, 
while the patient goes rapidly on to his death. 

In some cases of strangulated hernia the pain begins about 
the umbilicus, and thence, as the severity of the lesion increases, 
radiates to the region of the strangulation. 

Umbilical hernia is generally associated with considerable 
local and referred pain, most of which is probably due to traction 
on the stomach from the involved omentum, adhesions existing be- 
tween either the stomach or the adjacent omentum and the an- 
terior abdominal wall. 

In INGUINAL HERNIA forcible extension of the thigh is painful. 
In some cases of inguinal hernia, also, the pain may be felt in 
the epigastrium, and radiates to the back, as in a case reported by 
Witherspoon (125, p. 219), in which the patient complained of 
pain in the epigastrium radiating to the back, and of tender areas 
on either side of the vertebral column opposite the eighth and 
ninth thoracic vertebrae. Abrupt pressure over the epigastrium, 
centrally, and to either side, over the recti muscles, excited severe 
paroxysms of pain. Gradual pressure was well home. Operation 
relieved the condition. 

The following is a case of pain due to inguinal hernia. 

The patient complained of pain, or rather of a dragging sen- 
sation, running from the region of the pubic spine do^vnward and 
inward to the scrotum. This pain was made worse by walking, 
by lifting, or even by sitting, and was eased on lying down. 
He would be all right in the morning, but as the day wore on he 
would become so ill that he would have to give up his work, which 
was that of a driver on a grocer's wagon. On releasing the 
hernia, the pain entirely disappeared. The sac did not seem to 
be adherent to the surrounding fascia. 

Stockton, in speaking of inguinal hernia, describes a condition 


in which the complaint is pain generally referred to the lower 
quadrant of the abdomen; it is of a coliekj character, and is some- 
times burning. There may also be present continuous suffering. 
These symptoms are relieved when the patient lies down, and are 
increased on active movements, also in lifting. They appear and 
disappear at irregular intervals. Examination discloses a patu- 
lous internal ingiiinal canal, not large enough to permit a well- 
marked hernial protrusion, but sufficient to cause a bulging outward 
of the peritoneum, which is made worse by coughing or straining. 

Epigastbic TIekxia. — Epigastric hernias sometimes simulate 
gall-bladder or duct disease, or even a gastric disorder. They 
are to be differentiated from the small subcutaneous tumors found 
in the epigastrium, and are due to the protrusion of small, fatty 
masses through openings in the anterior abdominal wall. 

Hernias of the anterior abdominal wall sometimes produce 
symptoms of pain which disappear on lying do^vn. Examination 
may elicit no apparent abnormality, and the physician is at a loss 
to account for the persistent cryptogenic pain which recurs so regu- 
larly on motion, or on the performance of tasks involving an in- 
crease of the intraabdominal pressure. In many cases, while a 
superficial examination shows nothing, a more thorough one may 
reveal some slight thickening, or some little localized swelling of 
the abdominal wall. When this is found, hernia should be 
thought of. When small, there are no absolute diagnostic criteria 
of a hernia of this character; but if it is large and reducible, 
the gurgling accompanied by the disappearance of the tumor on 
reduction indicates the condition. McEwen (919), in speaking 
of small umbilical hernias, with a very narrow and distensible 
sac, states that the pain (violent abdominal pain) frequently 
comes on at an early stage, before any prominent external tumor 
has appeared, and he attributes the pain in such cases, in part, to 
the cupping of a portion of the bowel in the narrow mouth, and 
in part to the distention of the narrow mouth, causing pressure 
on, and irritation of, the peripheral nerves. 

The pain of femoral hernia in the male may sometimes be 
referred to the penis. 

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History. — The question of the sensibility of the abdominal 
viscera is one which has been mnch discussed, and, at the present 
time, it cannot be stated with certainty that the problem has been 
definitely solved. As long ago as 1753 Haller had noted that he 
failed to obtain evidence that the internal viscera were sensitive 
to painful stimuli, but it has become increasingly evident that the 
nervous mechanisms of the visceral activities are exceedingly mani- 
fold, and that no adequate explanation of their functions is possi- 
ble without a searching investigation of their rich nervous supply. 
The work of Lennander and Mackenzie seemed to point to the 
fact of there being no pain fibers in these nerves, but that of Ross, 
of Kast, and Meltzer has shown that the observations of previous 
experiments were faulty and that the ordinary tests which they 
used for the elicitation of pain phenomena in the viscera, which 
were the same as those used to elicit pain response in the skin, 
were not suitable, since the viscera, because of their structure and 
position, are non-responsive to these .stimuli, but may respond to 
other forms of stimuli than do the skin and mucous membrane. 

The ordinary facts of digestion prove the response to chemi- 
cal stimuli, and also to those of heat and cold, and it is becoming 
apparent that some modification of the earlier views must take 

The sensibility of the abdominal organs has been, for many 
years, a question of debate between two opposing schools, the one 
maintaining that the abdominal viscera of themselves were not 
capable of producing pain phenomena, the other holding that they 
were. Evidently both were right to some extent, for it has been 



found that organs which, under normal conditions do not produce 
pain will, when inflamed, give rise to pain phenomena (Rosthorn). 
However, in many cases it must he admitted that the sensibility 
to pain shown by the abdominal organs is very unusual, for in 
many cases operative interference may be undertaken without 
excessive pain production, ovariotomies having been performed 
by Eiedel (865) and Johnnen without any especial pain. The 
uterus is painful only when inflamed (Bernard, 867). All varie- 
ties of abdominal operations were performed by Lennander with- 
out pain production, except when traction was made on the mesen- 

For a better understanding of pain production in visceral 
disease, it may be well to review the innervation of the abdominal 
viscera. The innervation of the viscera is from both the cerebro- 
spinal and the sympathetic system. The cerebrospinal or medul- 
lated fibers are carried in the vagus and in the splanchnics, and 
are distributed to the various abdominal plexuses. Where they 
finally terminate is an undetermined question, but it seems likely 
that they end in the mesentery. The sympathetic has its own 
special nerve system — its fibers pass on farther than those of the 
cerebrospinal system, and are ultimately distributed to the ab- 
dominal organs, whose functional activities they coordinate and 
regulate. They consist of vasoconstrictor, vasodilator, motor, and 
inhibitory fibers, etc. (Tigerstedt). They originate in the lateral 
horn on the same side of the cord in which they are found, pass 
through the posterior ganglion into a nerve trunk, and finally end 
in a ganglion, from which fibers are carried to the ultimate distri- 
bution area. These ultimate ganglion cells have no connection 
with each other. All the sympathetic fibers do not arise in the 
cord, many of them arising in the posterior ganglia, or from the 
abdominal ganglia themselves. Mackenzie, Peterson (72), and 
others hold that the sympathetic system is oldest in origin, and 
that the cerebrospinal system is merely an outgrowth of the sym- 
pathetic, and has been built up for its protection. This may be, 
as remarked by ]\Iackenzie, the reason for its proneness to convey 
pain, one of the functionally protective sensations. In this way 



cotinuNicAimG upper lumbar oanoli* 



















Fig. 81. — Scheme of Innervation of Abdominal Viscera. 
The above diagrammatic drawing shows the reason for the tendency of 
diseases of the gall bladder, pancreas, duodenum, the pylorus and the 
greater curvature of stomach, to cause pain on the right side of the 
body; while lesions of the lesser curvature, fundus, spleen and pan- 
creas have a tendency to produce pain on the left side of the body. 
Drawing modified from Spalteholz. 



it guards, against injury, the internal organs supplied by the sym- 
pathetic, which ordinarily has no direct pain-conducting sensi- 
bility, as such is generally understood. The sympathetic contains 
both afferent and efferent fibers, but it is only the afferent which 
may, under unusual circumstances, be concerned in the conduction 
of pain stimuli. Ordinarily, these nerves are incapable of con- 
veying impulses which are interpreted as painful ; but under cer- 
tain modifications, such as are produced by injury, a change of 
irritability may take place, so that stimuli which ordinarily do not 
produce pain now give rise to the most excruciating agony. Such 
modifications have been observed, especially by Buch and Macken- 
zie. Buch, on correlating the researches of Wutzer, Florens, 
Brochet, Valentin and Longet with his own clinical findings, con- 
cluded that a normal sympathetic nerve is incapable of carrying 
pain-producing stimuli ; but that, when inflammation ensues, 
some change in its excitability occurs, so that, instead of the dull 
perception, which it previously had, it acquires an exquisite sensi- 
tiveness, so that pinching, pressing or dragging on it is very pain- 
ful. This increase of sensitiveness can also be produced by con- 
tinued electrical stimulation, or by stretching of or pressing upon 
the nerve (Lemmering). Ritter, after experimenting on dogs, 
concludes that the fibers conveying the impulses interpreted as 
painful run in the nerves distributed to the blood vessels, for he 
found that ligation of the vessels was much more painful than 
irritation of the parietal peritoneum or traction on the mesentery. 
This is in accord with the statement made in a previous chapter, 
to the effect that in the internal organs it is probable that the 
sensory fibers accompany the vasomotor nerves. Should such be 
the case, it is likely that the pain-conveying fibers are collected 
into the same ganglia, or in the ganglia associated with those of 
the vasomotor nerves. It has been found that the vasomotor cen- 
ter for the stomach and upper intestine is in the plexus cceliacus 
(Buch, 171; Pincus, 465; Budge, 466; Techlenburg, 467; 
Lowen, 468, and Boer) while Laignel Levastine located the vaso- 
motor center for the liver in the right semilunar ganglion, and thfe 
vasomotor center for the spleen in the left semilunar ganglion, 


and the vasomotor center for the small intestine and the upper 
part of the large intestine in the superior mesenteric ganglion. 
From the association of the vasomotor and sensory fibers, it 
would seem that these ganglia also are the sensory centers for the 
dependent organs. Lennancler, hov^ever, states that it is traction 
of the mesentery which, in turn, produces pull and traction on the 
sensory (cerebrospinal) filaments in its substance that produces the 
visceral pain. The apparent discrepancies between the statements 
of Eitter and Lennander may be due to the fact that Ritter's ob- 
servations were made during experiments on animals, while Len- 
nander's were made during abdominal operations. On one fact 
all observers are practically in accord, and that is that the 
parietal peritoneum is very sensitive ; and there is also concord 
in the belief that the viscera themselves are but slightly sensi- 
tive to pain. These latter views are in accord with observations 
of physicians from time immemorial. Perhaps the oldest exam- 
ple is in Xenoj)hon's "Anabasis," wherein mention is made of 
l^akarchos, the Arcadian, being wounded in the abdomen in battle, 
and coming in flight, holding his entrails in his hands. Then, as 
we pass down the ages, here and there examples are given of the 
insensitiveness of the internal viscera. Haller, about one hundred 
and fifty years ago (1753), noticed that the liver,- spleen, kidneys, 
heart and lungs possessed little sensibility ; that the parietal peri- 
toneum was slightly sensitive, while the visceral peritoneum was 
entirely without sensation. He also states that the subcutaneous 
coat is very sensitive, while the mesentery has no sensation. In 
this connection, I .shall quote in cxtenso from Meyers, who has so 
well described the progress of our knowledge in this direction. He 
says that "Bichat noticed, at the end of the eighteenth century, 
that electrical, chemical and mechanical stimulation of the organs 
supplied by the sympathetic system do not produce pain," This 
agrees with the clinical findings of Prony (343), who states 
(1821) that Bichat had seen dogs devouring their own intestines 
and tearing their own peritoneum, which had prolapsed through 
abdominal wounds. Many observations have been made on man, 
seeming to show absolute insensitiveness of the abdominal viscera 


(Mitchell, 263, in the year 1872 ; Bier, 331 ; Mackenzie, 332 ; 
Lennander, 380; Hofmeister, 869; Gushing; Block, 8Y0; Mitch- 
ell, 840; Partsch, 871 ).i 

The absolute reliability of these deductions has been ques- 
tioned by Kast and Meltzer, and more recently by ISTeuman. Kast 
and Meltzer claim that the insensitiveness to pain present in the 
abdominal viscera under local cocain anesthesia is due to the gen- 
eral toxic action of the cocain, which so reduces the sensitiveness 
of the internal viscera that they no longer respond to stimuli, to 
which, without the cocain, they would respond and which, being 
carried to the cerebrum, would be interpreted as pain. These 
deductions are apparently controverted by Mitchell (155, pp. 
200-201), who, under hypodermic subcutaneous injection of 
normal salt solution, was able, after the peritoneum had been 
opened and the intestine delivered, to seize it with a clamp, rub 
it with gauze, and prick it with a needle, all without the produc- 
tion of pain. 

The pain sensations from the abdominal organs are probably 

^ It is claimed by Lennander that none of the abdominal viscera is sen- 
sitive to pain, and that when pain occurs it is due to the following causes 
(given by Kast and Meltzer, 134, pp. 1017-1019). (1) pressure, sliding or 
pulling of the parietal peritoneum; (2) pulling of the mesentery, and thus 
irritating the posterior wall of the abdominal cavity, which is provided with 
pain fibers derived from the spinal nerves; (3) lymphangitis and lymphaden- 
itis occurring and reaching the nerves of the posterior wall; . (4) irritating 
toxic products or chemicals, like HCl in gastric ulcer, reaching the lymphatics 
of the posterior wall. 

Maunsell Moullin says that the effect of traction on the mesentery is 
the same, whether there is a "free mesentery or whether the peritoneum 
is reflected from the sides of the viscera, leaving a portion of the circumfer- 
ence of the bowel attached to the parietes by cellular tissue" (Moullin). In 
this case, besides the stimulation of the nerves in the peritoneum, there would. 
be traction upon the nerves in the connecting tissue. These nerves are de- 
rived directly from the cerebrospinal system, and any traction upon them 
would be referred as pain to the distribution area of their somatic branches. 
It is a well-known fact that the surfaces of the internal viscera are not 
painful to pressure, pinching or squeezing, nor to heat and cold. Their 
only function is reference of impulses having to do with the well-being of 
the organism; and in cases of inflammation, as suggested by Lennander (23), 
it is possible that toxins may be carried by the lymphatics to the nerve fila- 
ments, thus rendering them more sensitive, so that they respond to stimuli 
with a reaction which is called pain. Inflamed organs are slightly more sensi- 
tive than organs not inflamed. 


carried chiefly by the vagus and the greater splanchnics ; both con- 
tain medullated fibers, found, according to Edgworth, in the vagus 
at the level of the diaphragm. This view is opposed to that held 
by Lennander and Meyers (122), that the sensory fibers of the 
vagus do not extend below its recurrent laryngeal branch. Edg- 
worth also makes the observation that on the warming of the 
vagus its conductivity seems to increase. 

As to the manner of production and conduction of the visceral 
pain impulse little is known, though it is held that the pain is: 
(1) "due to induction of a current in adjacent fibers in a manner 
comparable to the electrical induction in two adjacent but uncon- 
nected nerves" (probably not correct) ; or (2) that the ''nerve cen- 
ter, spinal or cerebral, which receives the afferent impulses is so 
unduly excited that in its disturbed condition it attributes the 
afferent impulses to the wrong afferent nerve" ; or it may be possi- 
ble (3) that "transference may take place in the sensorium." 
Although the method of the production and conduction of the 
impulse is in doubt, yet no doubt exists as to the actuality of its 
presence. A peculiarity of its perception is' that it is not felt in 
the organ in which it is produced, but is referred or reflected to 
the body wall, where it becomes either the so-called somatic pain, 
or is perceived as a form of hyperalgesia.-^ 

Location of Pain. — That the pain of visceral disease is not 
necessarily located directly in the involved viscera may be seen 
from the following : 

(1) On movement of the involved organ there is no change 
in the character or location of the pain : 

(a) Movement of the heart produces no change in the char- 
acter of the anginal pain. If the pain were in the heart itself, 
each contraction of the heart would produce a change in the char- 
acter of the pain. 

(6) Peristaltic contraction of the stomach produces no change 
in the type of the pain of gastric ulcer ; also, changes in the posi- 

' This view has recently been very strenuously opposed by Hertz, who 
claims that pain sensation can reside in the internal viscera themselves 
(Hertz, 106b, p. 48). 


tion of tlie stomach due to respiration produce no change in the 
location of the pain. If the pain were located in the stomach, 
movement or change in the position of the organ would of neces- 
sity produce a change in the character or location of the pain. 

(2) The pain is not located directly over the diseased area 
in the involved organ ; indeed, it may not even be over the organ 
at all: 

(a) Cardiac anginal pain may be felt down the arm or even 
up in the neck, 

(6) Pain of gastric ulcer is not directly over the site of the 
ulcer, as has been proved, time after time, by operations. 

(3) The area of hyperesthesia may be distributed over a 
much wider area than that under which the organ is located. 

Transference of Pain. — Because of the apparent non-location 
of pain in the diseased viscera producing it, many attempts were 
made to explain the relationship between the area of pain and 
disease in the viscera. The most successful of these was by Head, 
who, in a thesis read before the University of Cambridge, in June, 
1892, and before the lieurological Society of London, l^ovember 
10, 1892, first oj)ened the way for the study of peripheral sensory 
manifestations of visceral lesions. He claimed that the manner of 
transference of pain sensation is this: that the stimulus affects 
the perijDheral distribution of a nerve distributed to a viscus, and 
that this stimulus is carried to the cord and enters the sympathetic 
system through the sensory root posterior to the ganglion. In the 
cord the nerve cells of. these fibers (from the sympathetic) come 
into intimate contact with the cells of the fibers from the periph- 
eral sensory system, and incite them to reaction, so that stimuli 
occur, and are transmitted to the brain, so that the brain centers 
perceive them as coming from the peripheral distribution of these 
same somatic or body nerves. 

By a reference to Figs. 31, 32, 33, it may readily be seen how 
the stimulus can be reflected from one set of neurons to another 
set; and it is thus that the excessive irritative stimulus arising 
in the splanchnic area is interpreted in some distant area as pain. 
Head has laid down a law particularly applicable to this state, 



namely, "that where a painful stimulus is applied to a part of low 
sensibility, in close central connection with a part of much greater 
sensibility, the pain produced is felt in the part of higher sensi- 
bility, rather than in 
that of lower sensi- 
bility to which the 
stimulus is actually 

W i 1 a ni o w s k i ' s 
(109 b) experiments, 
while confirm - 
ing Head's deduc- 
tions, show, in some 
cases, areas of re- 
duced sensibility cor- 
responding in outline 
to the areas of in- 
creased sensibility in 
other cases. He be- 
lieves that this hypo- 
algesia obeys the 
same laws and is 
subject to the same 
influences as the cor- 
responding hyperal- 
gesia, and that both are of the same origin. 

In this relation it was noticed by Mackenzie that in but very 
few cases does the hyperesthesia associated with visceral disease 
occupy the entire area of distribution of a particular nerve, as 
the area of cutaneous hyperesthesia associated with cardiac dis- 
ease does not extend throughout the entire area of distribution of 
the fourth dorsal nerve, but is generally confined to the skin on 
the anterior surface of the chest. It does not pass around to the 
posterior surface; also, it is sharply delimited at the clavicle, and 
does not spread upward into the area of distribution of the fourth 
cervical, which lies above the clavicle. It may extend down the 

Fig. 82. — Figure Showing the Anterior Dsi- 


AND Twelfth Dorsal Nerves. 
The shaded parts indicate the areas in which 
pain is most frequently observed in abdominal 
visceral disease. 


inner side of tlie arm and forearm into the areas of distribution 
of the second and third dorsal. Mackenzie (110b) claims that 
these fields of hyperesthesia are not accurately defined, that they 
may overlap each other, and that they are not particularly limited 
to any definitely defined, special area. These areas of hyper- 
algesia of Mackenzie are most likely nothing but the zone areas of 
hyperalgesia, as described by Head, whose work at that time was 
unfamiliar to Mackenzie. 

In some cases the visceral lesion may produce an irritable 
focus in the cord, so that stimuli coming to this place would be 
perceived as pain, while normally they would not be so per- 
ceived, or, in some cases, would not be felt at all. For instance, 
the liver and the stomach receive their nerve supply from the 
same segment of the cord. Liver disease may produce such an 
irritation of this segment, that, on the entrance of food into the 
stomach, the nerve impulses from the stomach to the cord, which 
ordinarily are not painful, would then be perceived as painful. 
Such examples we all have seen, and, in many cases, they lead to 
a wrong diagnosis (Mackenzie). 

Persistence of irritability of associated segmental areas of the 
cord may explain the presence of hyperalgesia, due to excitation 
of these associated areas. Thus, in a case of gall-stone colic (Mac- 
kenzie), in which there was jaundice, there was also extreme hy- 
peralgesia of the skin of the upper part of the abdomen, especially 
marked in the epigastrium. This persisted for some days after 
the stone had been passed and had been found in the stool. Dur- 
ing the time the hyperalgesia persisted food taken into the stom- 
ach produced severe pain in the epigastrium. With the disap- 
pearance of the hyperalgesia of the skin the pain on taking food 

Mackenzie, in continuing, says that "here there seems little 
doubt that the stimulation, set up by the ingestion of food, which 
passes to the spinal cord normally unperceived, reached that por- 
tion of the cord which had been abnormally excited by the gall- 

1 This association of pain with the ingestion of food may also be due 
in many cases to the associated peristalsis set up in related organs by the 
entrance of the food into the stomach. 


stone colic, and had hypersensitized the centers of the cutaneous 
nerves for pain which supply the epigastric region." 

Shock, also, sometimes affects certain cord areas, as in per- 
sons who experience pain in a certain area (hyperalgesic) when 
startled. Mackenzie's explanation is that when startled a stimulus 
passes down certain tracts in the spinal cord, affecting normally 
the centers of the muscular nerve supply, as evidenced by the 
sudden contraction of nearly all the muscles in the body. The 
stimulus is not of sufficient strength to affect the sensory nerve 
centers in a healthy cord, unless there are abnormally irritable 
foci in the cord. However, if such should be present, the stimulus 
in passing through them affects the excitable sensory nerve centers, 
and pain arises and is referred to the peripheral distribution of 
the nerves stimulated. It may also happen that pain is produced 
by a stronger and more powerful contraction of the excitable and 
hyperalgesic muscles.' 

Some mention should be made of the views of Hertz, who has 
carefully discussed this whole question in his 1911 Goulstonian 
lectures (''Sensibility of the Alimentary Canal"). He points out 
that Lennander and Mackenzie did not take into consideration 
the fact that a nerve ending may be sensitive to one form of stim- 
ulation and may be insensitive to another. The one is an ade- 
quate, the other an inadequate stimulus. The eye does not react 
to sound stimuli, nor the taste buds to those of light. Thus, the 
abdominal viscera, not being exposed to touch, are probably not 
stimulated by touch stimuli, but that they react to adequate stim- 
uli there is no question. All that the older observers showed 
was that pinching, pricking, cutting were not natural, adequate 
stimuli. The fact of the matter is that the abdominal viscera are 
exquisitely sensitive to deep-pressure stimuli, such as those pro- 
duced by tension. Thus, slight distention of the intestinal mus- 
cular coat leads to discomfort, and marked stretching to severe 

The normal stimuli reactions in the intestine are those of 
contraction and relaxation ; these two are going on continuously. 
There is, as Meltzer has pointed out, a law of contrary innerva- 


tion, which permits of this wave of contraction and relaxation, 
and any interference with this law, such as occurs in colic, in 
obstructions, etc., gives rise to paroxysmal and severe pain. 

The pains of gastric ulcer and duodenal ulcer are to be thus 
interpreted. In colic an abnormally strong peristaltic wave 
occurs in one part of the alimentary canal, the part immediately 
below which should normally relax, following the law of con- 
trary innervation, is unable to do so, owing to organic disease, or 
to spasm; the intermediary segment is thus subjected to steadily 
increasing pressure, which soon produces pain, the distention be- 
ing the adequate stimulus. 

Hertz believes that the only cause of true visceral pain is ten- 
sion. Thus, a study of the visceral pains resolves itself into an 
analysis of the two forms, the tension pains and the reflex pains, 
which, as has been pointed out, are exceedingly rich and varied, 
and of great diagnostic value topographically. 

Even with the adequate stimulus, however, the intestines are 
much less sensitive than is the skin to its adequate pain stimuli. 
The inaccuracy of localization of the tension pains is no argu- 
ment against them, since the brain is the perceiving organ and 
it registers the general topography of an organ, not its variations 
in location, as, for instance, in the movements of the stomach. 
Thus, there is no valid reason why the pain of a gastric ulcer 
should vary with every movement of that viscus. With the vis- 
cera, however, which move the least, the localization of pain re- 
mains the most stable,, other things being equal. 

Should the resistance of the patient be lowered from any 
cause, such as occurs in the anemic and weakened state which 
follows upon a severe fever or illness of any kind, it has been 
found that reflected and referred pains are much more likely to 

After the elicitation of referred or reflected pain, it is neces- 
sary to localize the viscus producing it. The technic is the fol- 
lowing: (1) delimit the area of hyperalgesia as nearly as pos- 
sible, and orient it with a cord segment; (2) find out what or- 
gans are supplied by this segment; (3) examine the organ or or- 


gans for disease; (4) see if, by manipulation of the organ, the 
pain can be reproduced. 

The transmission of stimuli to the cord also affects the mus- 
cular centers which lie adjacent to the sensory centers involved. 
These stimuli augment that which is normally present in the 
muscle, and, instead of the normal tonicity, cause a state of tonic 
contraction. This contraction may be limited to a portion of a 
muscle, may involve the entire muscle, or may affect several 
muscles whose centers lie adjacent to each other. This muscular 
center hypersensibility also accounts for the exaggerated reflexes 
(principally abdominal) which are so often present in visceral 

As irritation of the viscera causes pain to be referred to 
certain areas, it has been found that stimulation of these areas 
also is referred back and causes reflex changes in the viscera. 




The lesions of the abdominal viscera producing pain are prin- 
cipally those which cause contraction, active spasm, or excessive 
passive dilatation of the involuntary muscle fiber in the walls of 
these viscera. Inflammation of the viscera also causes pain; but 
in many cases ulceration of a hollow viscus may exist for years 
without producing the slightest distress. This is well exempli- 
fied in ulcers of the stomach, gall bladder and appendix (Moullin 
and others). 

In nearly all cases in which a severe and long contraction of 
a hollow organ is present, there is, above the area of contraction, 
an area of dilatation, so that, at the junction of the contracting 
segment with the dilating segment, a place is present where trac- 
tion on the mesentery is severe and prolonged. It is likely that 
this traction and pulling cause the excruciating pain of intestinal 
and other hollow viscera colics.^ That excessive passive dilatation 
of an abdominal organ may cause pain, is verified in many cases, 
such as when tympany of the stomach or colon, with severe pain, 
comes after operation. After relief of the dilatation by the pas- 
sage of the stomach or rectal tube, the pain disappears. Many 
have experienced the sense of discomfort and distention after the 
ingestion of a hearty meal, and it is easy to understand how this 
disagreeable sensation, if the distention of the stomach were pro- 
longed beyond the limits of its normal capacity, might be in- 

1 Hertz claims that colic is due to an irritation directly on the sensory- 
terminal fibers in the muscle layer of the visceral walls. 


creased to one of actual pain. There are many cases, also, in 
which, during dilatation of the stomach for the purpose of record- 
ing its capacity, the patient complains of a sharp pain in the 
epigastrium. These are but isolated examples of conditions which 
are very common. 

In the spasmodic contractions and the dilatations of hollow 
viscera the pain i§ generally referred to the body wall, and hence 
is called somatic. The point of reference, in many cases, is some 
distance away from the location of the lesion. Thus, the pain 
felt in stomach distention is in the epigastrium, immediately be- 
neath the ziphoid cartilage, at a point that is somewl^«^mote 
from the region of the stomach as projected on th^aHnominal 
wall. The logical way to explain the apparent non^Hociation of 
the area in which the pain is felt with the or^^Hn which it is 
produced is that these remote regions are ij|^Wation with one 
another by means of nerve connections. Aj^Kplanation of this 
seeming inconsistency may be formed fron^i study of cord zones, 
as elucidated by Head. It is known that the stomach is supplied 
by the seventh, eighth and ninth dorsal visceral zones, and that it 
is especially related to the seventh zone. It is also known that 
the maximum point of tenderness and sensibility of the seventh 
zone is in the epigastrium, immediately beneath the ziphoid. 
Therefore, in any lesion of the stomach which may be painful, 
the pain, as a rule, is reflected to this point, or to an analogous 
area on the back opposite the ninth or tenth dorsal spine. These 
pains are spoken of as reflected pains, and should more properly, 
perhaps, be considered under the class of pains which are felt at a 
distance from the lesions causing them, such as referred, reflected, 
transferred and associated or sympathetic pains. 

Referred pain is frequent in lesions of the nerves or of the 
centers of these nerves, which supply the integument of the an- 
terior abdominal wall. 

Under referred pains are to be placed those due to tabes 
dorsalis, tuberculosis of the vertebrie, fracture of the verte- 
brae, osteoarthritis of the spine, insufficiency of the vertebrae, 
spinal meningeal inflammation or tumor, neuritis of the lumbar 



or dorsal nerves, pressure by growths, inflammatory products, or 
broken ribs upon the nerves, pinching of the nerves (especially 
of the last two intercostals) between the adjacent ribs, diaphrag- 
matic pleurisy and rheumatism of the diaphragm, and aneurysm of 
the abdominal aorta. Acute mediastino-pericarditis, from direct 
extension, sometimes causes pain to be felt in the higher epigastric 
and lower breast region. For a proper consideration of all these 
pains, the reader is referred to the section under which referred 
|)ain is considered. 

Reflected abdominal 'pains are the most common variety, and 
probably number fifty per cent, of all varieties of visceral pain. 
They are the result of a stimulus applied either to a sympathetic 
or to a cerebrospinal nerve. This stimulus is carried to the 
posterior horns of the cord, and actively stimulates other asso- 
ciated sensory fibers. The stimulus is then perceived as pain, 
and the sensation -is referred to the peripheral distribution of the 
stimulated sensory nei^'ons, and thus it occurs that the peripheral 
distribution of the pain may be in an altogether different region 
from that in which the stimulus originated. 

Transferred atdominal yain is that form of pain in which the 
impulse is transferred, either directly across the cord to the other 
side, or to a higher or a lower level in the cord, thus changing 
the location of its peripheral distribution to a higher or lower 
level on the body wall. This is one of the most annoying pains 
to interpret. It may be found in the opposite side of the abdomen 
in appendicitis, pus tubes, diseased ovaries, renal calculus and 
pelvic peritonitis. Pain transferred to a higher or a lower level 
than that of the disease is illustrated by the abdominal pain in 
pneumonia (q. v.), the clavicular pain in extrauterine pregnancy, 
and the pains over the fourth costal cartilage (left side) in disease 
of the common duct. 

The shoulder pain, which may be present in diseases of ab- 
dominal organs, has been considered by Peter to be due to phrenic 
nerve irritation, which carries the stimulus to the roots of the cer- 
vical nerves, from whence the sensation is referred as pain to 
their area of distribution (Mackenzie and Peter). 


Sympathetic pains are sometimes produced when the irrita- 
tion of a center in the spinal cord is so great that other adja- 
cent centers are stimulated and send impulses to the brain, 
so that pain is also interpreted as coming from their distri- 
bution areas. This may happen in acute appendicitis when 
the cord segments above and below the segment connected with 
the appendix are irritated and refer pain to their area of dis- 

By reference to the diagram of pain paths, it may readily be 
seen how the various paths are propagated and conveyed. It 


Regional Pains. — For the zone segments involved in disease 
of the different viscera see Figures 24, 25, 26. Each zone segment 
has one or more maximal points of tenderness which are 
sensitive in any painful disease of the viscera supplied by this 
special segment. It should be noticed that the term "painful" 
diseases of the viscera is used; for, as is known, every disease of 
the abdominal viscera is not painful ; and while the majority of 
the visceral diseases at some period of their development become 
painful, there is a well-defined percentage which never do. The 
peculiarity of these nonpainful diseases may be accounted for 
from the fact that, in the evolution of the disease, the parietal 
peritoneum or the peritoneal attachments, as the mesentery, meso- 
appendix or mesocolon, have never been involved. We have 
already seen that Lennander explained all abdominal pain as a 
result of pulling, pressure or traction upon the peritoneum. In 
this i-elation, I would like, by means of an interpolation, to call 
attention to the experiences of physicians of a previous genera- 
tion, who frequently groped in the dark in a vain attempt to cor- 
relate the symptoms and the disease seen in their patients. A 
case in point is one in which pain extended from the midline 
posterior above the hip to the midline in front, in which shingles 
were present. The patient, a woman, died on the third day of 


the disease, and on antopsy an inflammation of the peritoneum 
and appendix was found. "During life it was quite impossible 
to form a reliable opinion as to the nature of" the lesion which 
gave rise to the pain. In view of our later knowledge, we would 
be able to diagnose the difficulty with ease'*' (McCall Anderson, 
860). A full discussion of these views will be given in a subse- 
quent chapter. 

One of the first results of abdominal pain is the crippling of 
the resj^iration. This is noticed especially in men, who are accus- 
tomed to use the diaphragm in respiration much more than 
women. Where painful intraabdominal disease occurs, the dia- 
phragm partakes of the reflex of all other muscles, and becomes 
rigid and motionless, so as to protect the diseased area. As a 
consequence, abdominal respiration is hindered or abolished. 


After this necessarily brief consideration of the pathology of 
various abdominal pains, it is in order to consider more closely, 
and in a more detailed manner, the routine examination for ab- 
dominal pain and tenderness. After that, it may be permissible to 
review the various divisions of the abdomen, and the pains which 
lie within their borders. In the examination of the abdomen for 
pain, the routine is as follows : 

Localization of Pain. — The patient should be recumbent, 
the shoulders raised, knees flexed, mouth open, and the breath- 
ing regular and easy. The examiner's hand should then be laid 
flat over the abdomen, at first with very slight pressure, to elicit 
general tenderness ; then the fingers should be pressed in with 
more force, in order to elicit localized tenderness at special points. 
The tips of the different fingers should now be successively de- 
pressed, in order to define more accurately the localization of the 
area of tenderness. After the location of an area of tenderness, 
it is well to determine its extent by concentric palpation. Con- 
centric joalpation is made by starting from the periphery and 
gradually making pressure towards the point of gi-eatest tender- 



ness. In this way the area of hypersensitiveness and the point of 
greatest pain are determined. 

Localization of the Organ Producing Pain.— After deter- 


Gall bladder 


Enlarged liver 



Lead colic 



Floating kidney- 


Fallopian tube 

Typhoid fever 

Referred pain 




Aneurysm of 




Fig. 83. — Anterior View of Abdominal 
Zones with Corresponding Organs. 

Midline pain may be due to hernia of the 
Unea alba. Pain over entire abdominal 
wall with tenderness on pressure indicates 
rheumatism of the abdominal muscles. 
Pain over any part of the abdomen may 
be found to be due to disease of the 
vertebra (caries, sarcoma, etc.). 

Intercostal neu- 

Referred pain 
in pleurisy, 



Kidney, ureter 
Descending co- 
lon (pericoli- 


Referred pain 
Girdle pain of 
loco motor 
ataxia, myeli- 
tis , spinal 
of abdominal 


Ruptured extra- 
uterine preg- 




Ovary and Fal- 
lopian tubes 


Ruptured ex- 


mining the presence of pain, it is in order to locate the organ pro- 
ducing it. For the purpose of localization, the abdomen is divided 
into three regions: (1) the upper, (2) the middle, and (3) the 
lower. The upper, which lies in the angle formed by the costal 
margins and a line connecting the lowest points on the costal 
arches, practically coincides with the epigastric area. The middle 



area lies between this zone and another line connecting the two 
iliac crests. Below this, and bounded at the base by the iliac 
and pubic bones, is the lower zone. Each of these areas is divided 
by a line extending from the ensiform cartilage to the pubes into a 
right and a left region, and the middle zone is divided by an 

Aneurysm of the 
descending aorta 





- Sacroiliac disease 

Fig. 84. — Posterior View of Abdominal Zones. 

imaginary line passing down the extreme lateral aspect of the 
body into an anterior and a posterior zone. 

In the annexed figure an attempt is made to outline the organs 
producing painful affections of each zone. In the upper zone, 
which is included between the diaphragm and the zonal line divid-, 
ing the middle zone from the upper, two lateral zones are present 
at either side beneath the ribs. They are called the hypochon- 
driac zones. Reference to the figures will show the organs giving 
rise to pain in each zone. 

Lesions Causing Epigastric Pain. — In considering the re- 
gional localization of abdominal pain it is well to pay at least 
partial attention to the great variety of lesions to which pain in 
the epigastrium may be due ; for, owing to the presence in the epi- 


gastrium of the solar-plexus, with its somatic peripheral distribu- 
tion,, pain in this region may be symptomatic of a lesion of almost 
any of the abdominal organs. The organs most frequently causing 
epigastric pain are : 

(1) The Stomach. — The pain is very often associated with 
vomiting, and generally bears some relationship to the ingestion 
of food. It is found in acute gastritis, gastralgia, hemorrhage, 
ulcer, perforation, injury, carcinoma, and obstruction from any 

(2) The Intestines. — The pain is due to hemorrhage, rupture 
from ulcer or injury, obstruction accompanied by increase of peri- 
stalsis, and the formation of a tumor. 

(3) The Appendix. — In all forms of acute appendicitis pain 
is present at first in the epigastrium, but quickly radiates to the 
right iliac fossa. 

(4) The Liver, Gall Bladder and Ducts. — In acute peri- 
hepatitis breathing is painful, and localized tenderness is present ; 
biliary colic is often followed by jaundice; in cholecystitis the en- 
larged gall bladder can be felt, and chills and fever are generally 
present; in rupture of the gall bladder or of the ducts symptoms 
of peritonitis rapidly supervene ; in carcinoma there are general 
signs of the disease, such as emaciation, and a positive hemolytic 
test. According to Riedel, ninety-seven per cent, of epigastric 
pains are due to gall-stones. 

(5) The Pancreas.- — In acute pancreatitis there generally is 
a history of previous gall-stone disease, with no cholecystitis, and 
no signs of a gastric lesion. 

(6) The Kidney. — In renal colic, pyonephrosis and hydro- 
nephrosis there are urinary findings, such as blood or pus in the 
urine, to indicate the disease. 

(7) The Spleen. — Splenitis, or traumatic rupture, may 
cause epigastric pain. 

(8) Ectopic Pregnancy. — Rupture of an ectopic pregnancy 
sometimes causes epigastric pain. 

(9) Locomotor Ataxia. — Locomotor ataxia causes a pain 
which may be referred to the epigastrium. There are also present 


other signs of the disease, such as Romberg incoordination and 
Argyll-Robertson pupil. 

(10) Pneumonia. — In pneumonia there are signs of lung 

(11) Pelvic Lesions. — Embolism of either the superior or 
the inferior mesenteric artery may be present, and produce epi- 
gastric pain with all the symptoms of bowel obstruction, but of 
much gTeater severity ; in these cases some other grave disease, 
from which the clot obstructing the vessel is derived, is also 

(12) Adhesions between any of the organs underlying the 
seat of pain may also be the cause of pain. 

Character of the Epigastric Pain. — If the pain in the epigas- 
trium is sudden and severe, and does not follow a straining effort, 
examination should be made for: 

(1) Appendicitis, which, if present, finally causes the pain 
to become localized in the appendix area. Typhoid fever, which 
in some cases, when it is of sudden onset, commences as a severe 
abdominal pain, and has often been mistaken for appendicitis. 

(2) Cholecystitis, in which the pain finally becomes local- 
ized to the right hypochondrium. 

(3) Acute hemorrhagic pancreatitis, in which the pain re- 
mains in the epigastrium. 

(4) Perforating ulcer, in which the pain remains where it 
first appeared for but a very short time, and soon, because of the 
development of peritonitis, becomes generalized ; or, in some cases, 
owing to extension of the exudate may at first be most severely 
felt in the pelvis. 

(5) In obstructed intestines the pain, as a rule, has a ten- 
dency to ascend toward the ensiform, until tympany becomes ex- 
cessive, when it is felt over the entire abdomen. 

(6) In perforated gall-bladder the pain remains in the 
region of the gall-bladder, or passes down to the appendiceal 
region, until generalized peritonitis develops, when the pain be- 
comes diffused over the entire abdomen. 

Sudden abdominal pain, following a straining effort and not 


confined to the epigastrium, may be clue to: (a) hernial strangu- 
lation; (b) ruptured extrauterine pregnancy; (c) ruptured ap- 
pendix; (d) tearing of peritoneal adhesions; (e) rupture of 
a cystic tumor ; (/) twisting of an ovarian tumor or cyst on its 

As they will not be extensively considered elsewhere, a little 
time will be devoted here to cysts in which the pain is of sudden 
onset, very severe, and paroxysmal, sometimes continuous. The 
cause of the pain is torsion of the pedicle (ovarian cyst or tumor). 
This causes an extravasation of blood into the tumor substance 
and a consequent rise of internal cystic or tumor pressure with 
tension and traction on the capsule. Such an increase is espe- 
cially apt to occur when the return circulation through the veins 
is obstructed. Should the capsule be lax, and the capacity of the 
tumor gi'eat, the pain from extravasation may not be great, even 
though symptoms of hemorrhage may supervene. Should the tor- 
sion occur in the pedicle of a wandering spleen or of a prolapsed 
kidney, the pain may be due to a beginning necrosis of the tissue, 
although it would seem more logical to define the increased in- 
tracapsular tension as being the active and potent cause. Pain, 
while of the greatest use in the diagnosis of twisted pedicle, is not 
of paramount importance. Richardson says that "a history of 
tumor, a sudden enlargement and tenderness in that tumor, pre- 
ceded or accompanied by pain, are sufficient to make the diagnosis 
of twisted pedicle." 

If the abdominal pain is due to irritation of the sympathetic 
fibers, it is present at first, as a rule, in the central part of the 
abdomen and later becomes localized more definitely to the area 
associated with the diseased organ or organs. On the contrary, 
if the cerebrospinal nerves are involved, from the development 
of a peritonitis, the pain is localized directly over the affected vis- 
cera. Bed clothing cannot be tolerated, and the abdominal mus- 
cles are rigid. The rigidity of the abdominal muscles over the 
diseased area is the result of somatic musciihir rcllcx cDiitrnctimi. 
Hyperesthesia of tlie skin over the affected viscera is .also present. 
This sensitiveness is generally not so sharply delimited as is the 


reflex tenderness from visceral disease. It is most severe at the 
site of the most severe inflammatory reaction, and diminishes 
concentrically from this point. 

Sudden abdominal pain is diffuse, or is localized in the umbili- 
cal region (where the solar-plexus, the so-called abdominal brain, 
the sensorium of the abdominal viscera, is located). This pain 
may be associated with shock and collapse, which, when present, 
are fairly certain indicators of a severe abdominal lesion. In 
the condition of shock the associated symptoms of importance are 
a rapid pulse, obliteration of the liver dullness (look for rupture 
of a viscus), and rigidity of the abdominal musculature.-^ 

Should the pain result from rapid and extensive extravasations 
of septic material, it is sharp, sudden and overwhelming. It is 
often ushered in by a feeling as though something had given 
way. At first it is continuous, violent, and almost unbearable; 
later it becomes paroxysmal and intermittent, or is dull and con- 
tinuous. The pain, which at first is localized sharply in the 
region of the extravasation, becomes generalized as the septic ma- 
terial spreads throughout the abdominal cavity. When the peri- 
tonitis becomes diffused and the bowel distention is excessive, pain 
usually subsides, and when it does so, it is a sign of gTave signifi- 
cance (Richardson). 

Pain Due to Functional Processes. — When abdominal pain 
occurs, inquiry should be made concerning the following points : 

(1) The relationship, if any, to the ingestion of food. If 

^ Lennander explains the diffuse abdominal pain present in the early 
stages of so many infectious processes in the abdominal cavity as being due to : 

(1) An increased sensitiveness of a large portion of the parietal perito- 
neum, owing to lymphangitis or peritonitis. 

(2) A considerable increase and irregularity of peristaltic action, which, 
in addition to pain, often produces a feeling of sickness and vomiting, and 
leads to one or more actions of the bowels at the commencement of these ill- 

(3) On account of increased sensitiveness, the movements of the stomach 
and intestines against the parietal peritoneum, and the stretching of their re- 
spective mesenteries, are felt as severe pains. 

(4) In most cases, however, the general peritoneal irritation soon passes 
away; only the part more especially infected remains in a condition of inflam- 
mation, and the abdominal pain becomes localized at this spot. 


there is any such relationship examine (a) the stomach and in- 
testine for a gastric or duodenal ulcer, or for adhesions, or the 
intestine for a volvulus or obstruction, in which case the pain, at 
first, is periodic and paroxysmal, and, later, continuous and of 
an aching, dragging character. If the pain is sudden and intense, 
especially if it commences in. the umbilical region and gradually 
becomes localized to the right side, examine for appendicitis. If 
the pain is continuous and increasing, it indicates that the local 
peritonitis is spreading. This is especially the case should there 
be a synchronous increase in the tenderness, (b) In pancreatic 
disease it may indicate a rupture of the duct or an acute hemor- 
rhage and inflammation, (c) Biliary disease, as a rule, causes a 
pain which comes on about the first or third hour after eating, 
at the time of the greatest intestinal activity, and is especially 
marked when percystic adhesions are present. 

(2) Relationship of pain to defecation indicates: (a) hem- 
orrhoids, which generally are associated with bleeding; (b) fis- 
sures of the anus, which often are associated with itching; (c) 
carcinoma of the rectum, in which bleeding is very marked and 
sometimes is present previous to the onset of pain; (d) ulcera- 
tions of the rectum, which, as a rule, are not painful, unless the 
sphincter region is involved. 

(3) If the pain occurs in conjunction with menstruation, 
the genital organs should be examined, the uterus, tubes and 
ovaries all being subjected to a close inspection. If they are 
affected, the pain, because of the congestion then present, becomes 
worse during the menstrual period. Sudden abdominal pain is 
often premonitory of a miscarriage. 

Pain Due to Intestinal Diseases. — A few facts worthy of 
attention are : That increased peristalsis of the bowel may, in 
case of obstruction, be a potent cause of abdominal pain. This 
pain is located across the middle of the abdomen ; never below the 
umbilicus in obstruction of the small" intestiue, but generally above 
in lesions of the large intestine (Mackenzie). In obstruction of 
the large intestine painful states arise. These are the result of 
the obstruction to the forward peristalsis, and are called colics. 


Of intestinal colics, there are those due to acute indigestion, 
in which the pain is nsnally accompanied by vomiting; those 
due to poisoning as by lead or hrass. (These metals irritate and 
cause constriction of the blood vessels in the intestinal walls, thus 
indirectly irritating the sympathetic nerve filaments and causing 
muscular contraction and colic. Pal claims that in lead colic the 
blood pressure is increased from one-half to twice the normal, and 
that this increased pressure irritates the terminal filaments of the 
sympathetic, and thus causes pain) ; those due to liernia, which 
are generally accompanied by vomiting; those due to uremia, which 
may precede other uremic symptoms by a considerable interval 
(Musser) ; those due to gall-stones, which are probably the most 
frequent cause of colic (here the pain, as a rule, is located in the 
right epigastric zone, but may be felt in the right lumbar zone 
anterior) ; and lastly, those due to renal calculus, which are very 
severe, and sometimes are mistaken for intestinal obstruction, 
chiefly because of the intestinal distention and inability to move 
the bowels, a condition often the result of large doses of morphia 
which the patient has been given. 

In children painful paroxysms frequently occur in the course 
of purpura. This disease, according to Guinon, is due to a toxic 
infective agent, with special action on the nervous system ; so that 
it seems very probable that the colicky pains are due to intestinal 
cramps, the result of a deranged peristalsis, which in turn is the 
result of malactivity of the nervous system. The ordinary colics 
of children are accompanied by a great restlessness, throwing 
about of the body, and interrupted cries. Relief comes on the 
expulsion of flatus (Kerr, 861). 

Perforation in typhoid is a cause of very severe and acute 
abdominal pain. In Manges' series of nineteen cases of typhoid 
perfo«ration, abdominal pain was the first symptom to appear in 
fourteen. In two of them, however, it was accompanied by a 
chill, and in two others by vomiting. Though not the initial 
symptom, it was present in seventeen of the nineteen cases. One 
of the best descriptions of the pain due to typhoid perforation is 
that given by Selby. What he says applies to perforation of any 


hollow abdominal viscus. He says that abdoniiiial pain is a most 
constant and reliable indication of perforation, depending, to be 
sure, on the mental condition of the patient and his appreciation of 
the sensation. The j^ain varies in degree, character and location. 
It may be so severe as to force a cry from a comatose patient, and, 
on the other hand, so mild as to attract bnt slight or no attention 
from a conscious patient. It may begin as a sudden, sharp, stab- 
bing and agonizing sensation, or may come on gradually. Its 
duration varies also. It is usually circumscribed and is lo- 
cated in the lower part of the abdomen near to the median line, 
or towards the right side, and, generally speaking, the more cir- 
cumscribed it is, the more keenly it is appreciated. Occasionally 
it is referred to the umbilicus and other parts of the abdomen, 
and even to the penis. If it be general at the start, as it some- 
times is, it may, in the course of a short time, become confined 
to the lower part of the abdomen. On the contrary, if primarily 
it is localized, and later becomes generalized, it strongly suggests 
progressive peritoneal infection. The value of pain, however, as 
a symptom, lies not so much in its limits, its severity, the manner 
of its appearance, and its persistence, as in the fact that it itself 
is present. Its modifying features, when present, may be weighed 
in proportion to their degree, but when absent may be ignored in 
arriving at a diagnosis. 

In one case of typhoidal perforation there was sudden pain 
in the lower abdomen, causing the patient to cry aloud ; soon after- 
ward there was intense pain in the penis (Allaben). The rela- 
tion of this penis pain to the perforation is difficult to determine. 

Abdominal pain may be caused by adhesions, for a discussion 
of which, see under Peritonitis. 

Abdominal Tenderness. — Tenderness on pressure, being close- 
ly allied to pain, may be considered in the light of a less-marked 
manifestation of that sensation. It usually accompanies pain, 
and not infrequently is present when actual jjain is absent. It is 
found within the same areas as is the associated pain, but is con- 
fined within more narrow limits. Thus, diffuse pain is occa- 
sionally associated with a localized tenderness. This feature 



renders tenderness of value in the determination of tlie approxi- 
mate location of the lesion. However, as such, it is not without 
fallacy. A widening of the tender area may be taken as an indi- 
cation of a spreading peritonitis, and, as such, is an indicator of 
greater reliability than an increasing diffusion of the pain. "The 
value of tenderness as a symptom is enhanced, needless to say, 
by its characterizing features, but, as is true of pain, its real 
value lies in its mere presence." 


Spreading pel- 
vic peritonitis 

Pelvic peritonitis 

Extension of the 

Morris's points 
McBurney's point 

Pressure over 
this area will 
cause pain if 
the ureter is 

Fig. 85. — Areas of Local Tenderness, when the Inflammation of the 
Appendix, Gall Bladder, and Fallopian Tube and Ovary Has 
Spread to the Peritoneum and Has Produced a Localized Peri- 

Morris's points are also shown, as well as the area in which pressure is made 
best over an inflamed ureter. 

When abdominal pain is present, tenderness should always 
be sought over the areas associated with the gall-bladder, the 
pylorus, the appendix, and the hernial openings. Abdominal 
tenderness is sometimes due to a hypersensitiveness of the ahdom- 
inal musculature^ such as is produced by prolonged coughing. 
This tenderness is generally in the epigastrium in the region of 
the recti muscles. 

Percussion is of value in determining abdominal tenderness. 
It often happens that, in percussing the abdomen, attention is 
drawn to a particular region by the wincing and involuntary 


shrinking of the patient from the percussing finger. This always 
indicates tenderness. After the attention is drawn to a particular 
area of the abdomen, more refined means of defining the degree 
and extent of tenderness (palpation and pin-prick pressure) may 
be used. Such measures have been described in earlier chapters. 

Types of Tenderness. — Tenderness is of two types : tempo- 
rary and permanent. Tenderness which is present temporarily 
over an organ may be due to the distention of the organs (stom- 
ach or intestines) with air or gas. As soon as the distention is 
relieved pain and tenderness cease. Chronic tenderness is more 
likely to be caused by inflammatory changes, especially in those in 
whom the abdominal wall or the parietal peritoneum is involved. 
Should the tenderness be superficial, and so acute that even the 
lightest pressure causes pain, it is probable that the condition 
is one of superficial neuralgia, such as is common during infec- 
tious diseases. On the other hand, deep tenderness is only of 
relative value, since even in many normal cases the forcing of 
the hand deep into the abdomen will cause pain. 

Reflected Tenderness. — In the consideration of tenderness the 
fact must not be lost sight of that tenderness is not always present 
over the organ causing it; for in many cases pressure on or over 
the infiamed or diseased organ will cause pain at some distant 
area, and pressure over this area is painful, even though it is at 
a distance from and has no direct connection with the organs 
causing the pain. This is a most important point in the diagnosis 
of disease, and should never be forgotten. 

A point of tenderness in cases of pelvic adhesions is given by 
Cumston, who says that "a symmetrical point of tenderness on 
the opposite side of the abdomen from McBurney's point will be 
found in pelvic adhesions." 

This point of tenderness, as given by Cumston, closely 
approximates the point of tenderness defined by Morris as being 
present in pelvic lesions. Morris gives his point as being one and 
one-half inches from the navel on a line running from the navel 
to the umbilicus. He claims that when this point is tender on 
the right side alone, appendicitis is present, and that when it is 


tender on both sides, pelvic disease is present. Tliis view has 
been controverted bj Hubbard, who ascribes to these areas of 
tenderness, even in cases of chronic appendicitis, only secondary 
importance. McBurnej's point, which is also a point of tender- 
ness in aj)pendicitis, is situated in the lower left quadrant of the 
right lumbar zone anteriorly, on a line drawn from the umbilicus 
to the anterior-superior spine of the ilium, and one and one-half 
inches from the anterior-superior spine. It has not the signifi- 
cance formerly ascribed to it (see Appendix). 


The posture of the patient, in cases of severe abdominal dis- 
ease, is characteristic. The patient assumes two general positions : 
in the first, the posture of abdominal protection, the patient is 
alert, ' and while with one hand he attempts to ward off any ab- 

FiG. 86. — Posture of Abdominal Protection Present in Peritonitis. 

In cholecystitis and appendicitis, the hands may be the reverse of what 
they are in the figure : the right hand acts as guard and the left as pro- 
tector. In salpingitis, the protecting hand is over the lower abdomen. 

dominal interference (touch, palj^ation), with the other hand he 
covers (without making pressure) the painful area. In the second 
form the patient, instead of warding off abdominal pressure, 
seems to find relief when pressure is applied to the abdomen. He 
is, as a rule, doubled up, with the limbs flexed on the abdomen, 



Fig. 87. — Position in Abdominal Colic, Assumed on Lying. 

and the belly muscles tightly contracted. In some cases the pa- 
tients make pressure on the abdomen with the hands, while in 
other cases they use for this purpose some other object (pillows, 
bolsters). In the first posi- 
tion inflammation of some 
of the abdominal organs is 
indicated, and if the sensi- 
tiveness is markedly in- 
creased peritonitis probably 
has already set in. The sec- 
ond position indicates some 
variety of colic, the parox- 
ysms of which are indicated 
by the exaggeration of the 
position which the patient 
assumes when the pain 
comes on. The patient, as 
a rule, lies down, or, if this 
is impossible, assumes a sit- 
ting posture, with the arms 
folded and the body bent, so - 

that pressure is made on the ^ 
1 1 Fig. 88. — Position in Abdominal Colic, 

Assumed on Sitting. 




To complete this chapter a brief discussion of some of the 
most common forms of abdominal pain is necessary. Among 
those most frequently encountered is renal colic, the pain of 
which is generally on the affected side, passes downward toward 
the pelvis, and is often very acutely felt in the testicle on the 
side of the disease. In the purpura of infants painful abdominal 
paroxysms are common (455). According to Musser, abdominal 
pain is often a precursor of uremia. This pain is usually situated 
in the right or left hypochondrium, and, when in the left hypo- 
chondrium, has been mistaken both for gastritis and gastric per- 
foration. Enteroptosis, particularly gastroptosis, may produce 
pain in the suprapubic region (Deaver). 

Keen reports a case of rupture of the rectus muscle, in which, 
at the time of the rupture, sudden, sharp pain was felt in the 
abdominal wall. Such a rupture may occur in a typhoid patient 
who is convalescing, and generally follows some sudden exertion. 
The symptoms of rupture are sudden, sharp pain and tenderness 
localized to the point of rupture. The rupture is generally accom- 
panied by vomiting. Examination shows a depression in the 
course of the muscular fibers, later accompanied by ecchymosis and 

If the pain is in the rectum, it may be caused by a pro- 
lapsed colon. 

Arteriosclerosis of the abdominal vessels also causes abdomi- 
nal pain, which generally is severe and paroxysmal. Eor a full 
discussion, see under Arteriosclerosis of the Mesenteric Arteries. 

A condition is described by Depage in which pain is due to a 
displacement of a rib. Examination will show that the eleventh 
and in some cases the tenth rib is projecting over the iliac crest. 
The pain is intermittent and is worse when the patient walks or 
moves about. Pressure over the ends of the tenth and eleventh 
ribs is painful, and pain is also experienced if the angles of the 
ribs are brought one over the other. The condition is most fre- 
quent on the right side. 


A rather rare and frequently overlooked cause of abdominal 
pain is anemia (Musser, 5). 

Functional Pains. — Richardson speaks of neuralgia of the ab- 
dominal organs as a cause of abdominal pain. This term, as a 
rule, is a misnomer, for nearly all cases of supposed abdominal 
neuralgia are due to some condition having a more definite patho- 
logic basis than is found in neuralgia. The only reason that these 
lesions are not properly diagnosed is that the search for their path- 
ology has not been sufiiciently prolonged nor assiduously enough 
pursued. While neuralgia may and does occur as a cause of ab- 
dominal pain, it is much less frequent than is supposed. 

The so-called functional pains are frequently classified as neu- 
ralgic, but in nearly all cases these pains can, by patient search, 
be shown to be due to organic lesions, sometimes obscure, but 
present nevertheless. Under functional pains, Richardson gives 
gastralgia, nephralgia, oophoralgia, and simple intestinal colic 
from gas. All except the last are recognized entities, but not 
in the same manner as is generally understood. 

Gastralgia is only a term, usually applied to a painful state 
of the stomach, having an unknown basic cause. In some cases, 
when it is due to a painful condition of the muscular structure, 
it should be called gastromyalgia ; on the other hand, if the nerves 
are affected, it should be termed gastroneuralgia. However, all 
painful conditions of the stomach, whatever the etiology, may be 
classed under the generic term gastralgia. So likewise painful 
states of the kidney and ovary may be called nephralgia and oophor- 
algia. But often, alas, when we suffix "algia" to the name of an 
organ, it means that we are but adding a cloak to conceal our 
ig-norance of the real cause of the pain which is present ; it means 
that we are naming the diseased state from a symptom instead of 
from the pathology. The careless use of these terms cannot be 
too strongW condemned, and they would be seldom employed if 
it were borne in mind that they frequently are but the indicators 
of ig-norance and sloth. 

The presence of abdominal pain in neurasthenics should 
always be a subject of considerable investigation before a defi- 


nite diagnosis is made. The neurasthenic is frequently subject 
to the delusion that there is something radically wrong in the 
abdomen, and even though operation and removal of an ovary or 
of an appendix may relieve the symptoms for a time, the pain 
soon returns, and is found in a new location, so that it is almost 
an impossibility to relieve this class of people, either with or with- 
out operation. Psychotherapy in the form of reeducation is 
probably at the present time the most efficient means at our com- 
mand of producing relief. 

After the review of pain, as given in the previous pages, it 
may be well to consider the time of life at which the different 
pains are most frequent. For this purpose, life may be divided 
into four periods : infancy, childhood, adult life and old age. In- 
fancy, with its sensitive and helpless condition, offers a double 
hardship to the examiner, for he not only has to elicit symptoms, 
but has to derive them without the patient's help. For this rea- 
son, pain, as a symptom of disease in infancy, is a factor of 
almost negligible value. It becomes important only as the infant 
grows older, and, by intelligent cooperation, is able to tell the 
examiner something of the type and character of the pain which 
he experiences. Yet, with all these drawbacks, even in infancy 
pain is of some little value. When the infant continuously cries 
and cannot be hushed by its mother, as a rule, it is suffering from 
some form of pain. The most common causes of pain in infancy 
are colic, gastroenteritis, and intussusception. In children one 
should look for these conditions, and, in addition, spinal caries, 
gall-bladder disease, appendicitis and pneumonia. In adult life 
all of the above, with the addition of gall-stones, gastroduodenal 
ulcer, pancreatic disease, hernia strangulation, and, if the patient 
is a woman, ovarian, tubal or uterine disease may be present. As 
old age comes on, the tendency to malignant growths increases, and 
in case of persistent pain one should seek for cancers. 

Care in Diagnosis. — As previously mentioned, tabes dorsalis, 
caries of the vertebrae and tumors of the spinal cord cause pain. 
These three conditions should always be thought of in those cases in 
which an abdominal pain is present without sufficient and definite 


cause. So often are thej mistaken for disease of the intraab- 
dominal organs that the physician must be very careful to exclude 
them before he arrives at any definite conclusion. Hovi^ell (lllb) 
speaks of cases of tabes dorsalis being mistaken for cases of appen- 
dicitis and operated upon. Lead poisoning should also be sought, 
and when the patient with colic is a painter, the gums should be 
inspected at once, to ascertain if the blue line at the edge is present 
(Burton's blue line). In lead colic, the abdominal cutaneous 
byperalgesia is absent (Robinson, 265). 

Intercostal neuralgia causes pain which is referred to the an- 
terior abdominal wall, and is likely to be mistaken for an intra- 
abdominal lesion. The presence of the pain points is a differen- 
tiating symptom (see ]^euralgia). 

Pneumonia frequently refers its symptoms to the abdomen, 
and in some cases so strongly that an abdominal lesion has been 
diagnosed. In many cases appendicitis operations have been 
performed -with negative results for appendicitis, and the oper- 
ator, to his chagrin, has found pneumonia symptoms developing 
during the course of the next few days. All cases of acute ab- 
dominal pain, with rapid pulse, rapid respiration, and high 
fever, should at once direct the attention to the chest. The ten- 
derness, also, is characteristic, in that in pneumonia the skin 
over the abdominal area in which pain is complained of is very 
tender, but deep pressure is well borne (Howell, Hood, Bennett). 
This is the opposite to the rule in severe abdominal diseases. 

Pleurisy has also been mistaken for abdominal disease, and a 
case is cited by Bennett (144, p. 1005), in which operation would 
have been performed for appendicitis had it not been that a band 
of tenderness extending around the abdomen above the umbilicus 
drew attention to the pleural involvement. 

Hilton claims that the abdominal pains of thoracic visceral 
disease are due to involvement of the parietal nerves, and a subse- 
quent reference of the irritation to tlieir distribution area. He 
says that the pleura is supplied by the intercostal nerves, an opin- 
ion which is disputed by Mackenzie. (See pleura.) 

Abdominal pain may also occur with obstinate constipation. 


Sharp, acute and agonizing; the pain of a colic 
radiates in different directions depending 
upon the location of the colic ; for instance, 
in gall-stone colic the pain radiates around 
to the back underneath the scapula of the 
same side. 

Eased by pressure: as in cases of gall-stone 
colic, the patient seeks ease by doubling up 
and making pressure against the abdominal 









"a % 

"d +^ 

















Sharp, acute, generally radiates along the 
course of a nerve, as in neuralgia of the 
tenth dorsal nerve, in which the pain 
radiates around from the tenth interspace 
to the area of distribution on the abdom- 
inal wall. 

Is excessively tender. The slightest pressure 
produces an excruciating pain. Pain can 
also be produced by pressure upon the nerve 
trunks and this pain radiates along the ter- 
minal branches. 












fe 3 











Dull aching, and if the inflammation is acute 
and engorgement of the vessels is excessive, 
the pain has a throbbing character. The 
pain also tends to radiate from the inflamed 
area outward towards the periphery. 


































When it does so occur, it maj come on rather suddenly. It gradu- 
ally increases with little or no increase in the temperature ; finally 
vomiting of stercoraceous material occurs and the diagnosis is 
made clear. 


Spasm and Rigidity of Muscles. — Spasm of the abdominal 
m,uscles nearly always accompanies abdominal pain, especially if 
the pain is severe. This symptom is lacking in those who have 
very lax or atrophied abdominal walls, and it is also much less 
marked in women than in men, because their muscular develop- 
ment is generally much less than that of men. On the other hand, 
severe rigidity of the abdominal wall may, in those of a very 
muscular build, supervene upon a very slight intraabdominal irri- 
tation. Localized rigidity is a good indicator of the region of the 
abdomen involved, for the contraction generally takes place im- 
mediately over the diseased viscus. Should abdominal rigidity 
gradually become lessened, while the toxic state of the patient 
gradually increases, it indicates that the lesion, whatever its 
nature, is increasing in virulence, and is becoming dangerous to 
the patient. This is particularly so if the leukocytosis, which has 
been present, decreases to, or even below, the normal level. Spasm 
of the abdominal muscles is of diagnostic value in differentiating 
abdominal from pelvic lesions, it being marked in abdominal 
lesions, and almost, if not entirely, absent in pelvic lesions. 

Visceromuscular Reflex. — In abdominal lesions, also, the so- 
called visceromuscular reflex (Mackenzie) may be present and 
render the diagnosis more difficult, especially since, in the abdomi- 
nal parietes, the muscles have the power of segmental contraction 
over an area of inflammation or irritation. These segmental 
masses of muscles are very deceiving to the palpating hand, and 
have been mistaken by the examiner for: (1) enlarged ovaries, 
(2) an enlarged and inflamed appendix, (3) tumors, intraab- 
dominal and parietal, (4) inflammatory exudates, and (5) intes- 
tinal tumors, due to volvulus, intussusception, etc. 


During every abdominal examination, the possibility of eon- 
fusing these reflex muscular contractions with tumors, etc., should 
always be borne in mind, and, since the rectus abdominis is mostly 
at fault, its nodal points should be carefully mapped out. One of 
these points occurs at the umbilicus and another between the um- 
bilicus and the costal arch. Any swelling due to contraction of the 
rectus would occur between these points and would be somewhat 
oblong in shape. 

In the diagnosis between these phantom and true abdominal 
tumors it is well to observe: (1) that a tumor may vary in its 
relative position to a fixed point (umbilicus) on the abdominal 
wall, but a contracted part of the rectus muscles does not so vary ; 
and (2) that while the tumor, which is the result of contraction 
of the muscle, may be so persistent and constant that sometimes, 
even under chloroform, it yields with difficulty, yet it ahvays 
does yield; while a tumor which is the result of organic disease 
is more clearly defined when, as a result of the anesthetic action 
of chloroform, relaxation of the rectus muscle occurs. 

Toxemia also has a restrictive action on pain perception, and 
if it is pronounced, abdominal pain is perceived very slightly, or 
not at all. As Musser remarks, when a hyperleukocytosis is 
present, with associated severe toxic symptoms, even though pain 
is absent, a serious lesion should be considered. 

Indicanuria, as an accompaniment of pain, is of considerable 
value in localizing the lesion to the small bowel. 

Polyuria. — Many painful conditions of the abdomen are asso- 
ciated with polyuria, and Osier has remarked on the frequency of 
polyuria in the later stages of typhoid fever. 

Relationship of Hysterical to Abdominal Pain. — Hysteria as a 
cause of abdominal pain is only mentioned to be condemned. It 
seems to be a term with which many clinicians hide their ignor- 
ance and diagnostic distress. The more a physician sees of ab- 
dominal pain, and the more frequently he follows his case to 
operation or to autopsy, the less seldom he makes a diagnosis of 
hysteria. It seems that nearly all so-called abdominal pains of 
hysteric origin have for their basis something more than a disor- 


dered nervous system. Under the shadow of this name are hid- 
den many cases of gall-stones, appendicitis and gastric ulcer. 
Many are the patients who go on to chronic invalidism or lie in 
too early graves because of the ignorance or inattention of their 
physicians to these facts. 

Abdominal incisions are frequent causes of abdominal pain. 
Since this is of vital importance to the surgeon, I quote from 
Maylard, who, to avoid pain as a result of abdominal incisions, 
recommends that the ''incision be made in the most favorable 
part of the abdomen ; that is, the part that has the fewest nerves, 
and that, during the operation, as little irritation or destruction 
as possible to the tissues of the wound be made." 

Post-operative abdominal pain, according to Maylard, is caused 
by irritation of the nerve endings. If it follows immediately 
after operation, it is due either to tight suturing or to the pres- 
sure exerted by encircling ligatures. Tension is generally indi- 
cated by a throbbing pain or ache. When the pain is due to tight 
suturing or to the ligatures, it follows almost immediately upon 
the operation, and generally is of a stinging, stabbing character. 
In some cases a nerve may be transfixed with a suture or ligature, 
and be a constant source of pain production. If the pain follows 
twenty-four to forty-eight hours after operation, it is due to in- 
flammation, with consequent swelling and pressure. When the 
inflammation is mild, little or no pain results ; but should it be so 
extensive that exudation is present, the pressure from the exudate 
upon the terminal nerve filaments is productive of pain, in some 
cases very severe. The distress which at first was intermittent is 
now continuous, and should a rise of temperature occur suppuration 
will generally be found to be present. Inflammation of the skin 
or subcutaneous tissues generally produces pain in the first twenty- 
four to forty-eight hours, while inflammation of the deeper struc- 
tures does not produce discomfort for longer periods. In case 
the inflammation is of the peritoneum or subperitoneal tissues, 
discomfort and pain do not make their appearance until about 
the eighth day after operation. If the patient is very obese, a con- 
siderable amount of effusion takes place into the wound, and, as 


Maylard remarks, unless drainage is provided, tension, inflamma- 
tion, and consequent pain will follow. 

Pain Referred to Extraabdominal Regions. — In disease of 
abdominal organs the pain is sometimes referred to an extraabdom- 
inal location. For instance, it is common to have pain in the shoul- 
der in diseases of certain abdominal viscera. This pain has been 
described as dne to irritation of the phrenic nerves, which convey 
the stimulus to the roots of the cervical nerves, to whose cu- 
taneous distribution the pain seems to be referred. This pain, 
along with an area of hyperesthesia of the skin of the shoulder in 
lung inflammation, has been attributed to diaphragmatic irritation 
by Mackenzie, although he also suggests that it may be due to the 
vagus terminations being involved. It is probable that the shoul- 
der pain, which is found associated with gall-stone and gall-blad- 
der disease, is due to involvement of the diaphragm in the in- 
flammatory process. Likewise, in certain cases of rupture of 
extrauterine pregnancy, we find that pain is present in this area. 
In these cases the pain may be due to pressure upon the diaphragm 
by the accumulation of extravasated blood (for it is a peculiar 
fact that, on standing, the pain often disappears). 

Absence of Pain. — Should abdominal pain be absent when nat- 
urally it should be expected, or if it should disappear before the 
natural termination of the disease would warrant its cessation, 
the patient should be examined for: (1) perforation of the viscus 
involved, (2) gangrene of the diseased organ, and (3) increase of 
toxemia to such an extent that the patient's faculties are dulled 
so that he is unable to perceive pain. 

When perforation of a viscus occurs, pain is temporarily re- 
lieved ; but the relief is due only to the incapability of perception 
which accompanies the shock produced by this condition. When 
perforation takes place the pulse generally increases in rapidity 
and becomes weak and thready. The temperature first falls and 
then rises, as infection and a generalized peritonitis ensue. Any 
localized tenderness which may have been present before the 
perforation now becomes diffused, and muscular rigidity, which 
before was restricted to one area, now becomes general. Should 


gangrene of an abdominal viscus occur, the temperature, because of 
consequent toxemia, may fall. That this fall is not beneficent, may 
be seen from the pulse, which is constantly increasing in rapidity, 
and from the increasing stupor and somnolence of the patient, 
whose appearance indicates that he is suffering from a most severe 
disorder. The disappearance of the pain as an indicator of im- 
provement is of value only if all associated symptoms improve con- 
comitantly with it. In many, though not all cases, the rapid dis- 
appearance of the cutaneous hyperalgesia occurs simultaneously 
with the onset of gangrene (Bennett, 142, p. 1005). Toxemia can 
be easily diagnosed by the increasing stupor and coma associated 
with it. However, even in the most advanced stages of stupor and 
coma, while the patient does not complain or cry out from pain, 
a close examination will disclose the facial expression of the most 
severe distress. 



Lips. — It is very rare for the lips to be afflicted with pain 
without noticeable organic change, although sometimes neuralgia 
of either the second or third branch of the fifth nerve seems to 
be particularly confined to either the upper or the lower lip. In 
this case we find that the lips are normal in appearance • but ex- 
ceedingly tender to pressure. The pain also comes in paroxysms, 
between which there is no pain and absolutely no tenderness. 
The principal organic changes in the lips producing pain are in- 
flammation and fissure. Inflammation of the lips is generally 
due to infection, which has entered either through an abrasion or 
a pustule. When it is present there is considerable swelling, and 
the pain is of a constant, throbbing character. The involved area 
is very tender to the touch, and motion is almost if not entirely 
abolished, so that it is very difficult to take food. When fissures 
are present linear abrasions may be seen running across the mu- 
cous membrane of the lip, and at the angles of the mouth, where 
they are very common. Opening the mouth is very painful, and 
the contact of the denuded surface with salty or acid substances 
is also very disagTeeable, so that the patient is averse to eating. 

Herpes of the lips is very common in the early stages of in- 
fectious diseases, and, as a rule, the vesicles are exquisitely ten- 
der. Herpes of the lips is frequently complicated by infection. 

Cheeks. — Pain in the cheeks may be due to inflammation or 
to neuralgia. Inflammation is generally not of local origin, but 
is the result of an extension from adjacent areas, such as the 
gums, or alveolar processes. When it is present the cheeks are 
kept at rest. They feel as though they were stiffened, and are 

TEETH 419 

hard and board-like. Tliere are also considerable swelling and 
a glossy appearance of the skin. Nenralgia (trigeminal) here is 
not different from neuralgia in other locations, and gives rise to 
the same signs and symptoms. A condition of the cheeks that is 
very painful is a vesicular formation on the internal mucous mem- 
brane surface. This is very disagreeable and, though it does not 
cause any subjective pain, the least irritation, such as the rubbing 
against it of the tongue, or of solid or liquid food, causes a very 
disagTeeable sensation. These vesicles are either the result of nerve 
involvement, such as is found in trigeminal herpes, or are but the 
reflex herpetic eruptions of digestive disturbances. If on the 
tongue an ulcer that is free or almost free from pain is found, 
syphilis or tuberculosis should be sought. In mild inflammations, 
such as those w^hich accompany stomatitis, there is moderate pain, 
which is increased on the ingestion of food. At the same time 
there are thick, sticky saliva, impaired taste, and often a slight rise 
of temperature. 

Teeth. — Sometimes, in cases of toothache, the aching may be 
due to hyperesthesia, a common accompaniment of pregnancy. 
Ordinary toothache is due to an irritation of one of the branches 
of the trigeminus by products of dental caries. At first the pain is 
more or less localized to the point of origin, but it gradually may 
become so accentuated that a general neuralgia results, and the 
entire side of the face may become affected. This may increase 
until the entire side of the head and neck is tender and painful. 
This extension can be explained by the rich collateral association of 
the trigeminus with the cervical nerves. Because of this close rela- 
tionship it is easy to understand how an excessive stimulation of 
one nerve can produce reactions in adjacent nerves. In some 
cases, after the extraction of teeth, pain may persist for several 
days, especially if gum-boils are present before the extraction, in 
which case the pain may persist for five or six days (Vosper, 

The most sensitive part of a tooth is the pulp and the agents 
causing the greatest reaction are heat and cold. Head claims 
that, until the pulp is involved, the pain remains local, but as 



soon as it is affected the local is changed into referred pain. 
Thus, in the course of destruction of a tooth three different vari- 
eties of pain are encountered : 

(1) The local, sharp pain, associated with destruction of the 
enamel and involvement of the dentine. It is easily produced 
by the sensitive dentine coming into contact with very hot or cold 
substances, drinks, etc. 

(2) The referred pain from involvement of the pulp cavity. 
It seems that each tooth has a separate area of pain reference ; 
for instance : 

Upper Jaw 

(1) Incisors 

(2) Canine 

(3) rirst bicuspid 

(4) Second bicuspid 

(5) First molar 

(6) Second molar 

(7) Third molar 

Lower Jaw 

(8) Incisors 

(9) Canine 

(10) Bicuspid 

(11) Second bicuspid 

(12) First molars 
iX^\ Second molars 

(14) Lower wisdom 

Eefeeence Aeea 

Frontonasal region 
^Nasolabial region 
Nasolabial region 
Temporal or maxillary 
Maxillary region 
Mandibular region 
Mandibular region 




Hyoid or mental 

Hyoid — also in ear and just be- 
hind angle of the jaw. The 
tip of the tongue on the same 
side is also tender. 

Superior laryngeal area 

(3) After the pulp is destroyed the referred pains cease and 
there are only local pains, due to involvement of the periodontal 
structures. For more detailed information, see Head, Brain, 
1904, pp. 406-415. 

Central trigeminus pain (tic douloureux), either frc 

fom m- 


volvement of the ganglion itself or its internal roots, or as a re- 
sult of pressure (cerebello-pontine angle tumor, neuroma), often 
leads to a faulty diagnosis of teeth pains. Many patients suffer the 
loss of one tooth after another in the vain search for the affected 
one. After the sacrifice of the teeth the dentist or physician 
wakes up to the fact that the disorder is central, and that a grave 
mistake has been made. 

Tongue. — The lesions of the tongue which are apt to give 
rise to pain are inflammation, fissures, ulcers, new growths, and 
vesicles. Inflammation can generally be traced to some abrasion 
or injury, or to an extension of inflammation from some adja- 
cent area; however, there is a unilateral inflammation (hemiglos- 
sitis) which is probably of neurotic origin. Fissures in the 
tongue, as in all sensitive mucous membranes, are apt to be very 
painful, because of the exposure of the sensory terminal filaments. 
This is also true of ulcers, which in this location likewise are 
very painful. 'New growths in the tongue give rise to a sensation 
of discomfort rather than to one of pain. Vesicles due to her- 
petic disturbances may appear on the tongue, and when they do, 
they cause great distress owing to their extreme sensitiveness. 
They generally are an indication of a central lesion, central herpes, 
though they may be, as are similar vesicles on the cheek, but 
a manifestation of disturbed digestion (reflex herpes). When 
due to herpes the vesicles generally appear on the posterior half 
of the tongue, which derives its sensory supply from the glosso- 
pharyngeal nerve. Tuberculosis and syphilis of the tongue are 
not painful unless there is a breaking down of the lingual tissues, 
with a consequent exposure of the sensory nerve filaments. 

In many cases a hyperalgesia of the tongue is an indication of 
hysteria, which, when present, generally gives rise also to para- 
gusia or gustatory paresthesia (disturbances of the sense of 
taste), the patient complaining either of the disagreeable taste 
of that which would otherwise be agreeable, or of the persistence 
of a bitter or of a sweet taste in the mouth when nothing has 
been tasted. This is a fairly frequent condition in neurotics, 
particularly those suffering from neurasthenia. 


The presence of small, painful lesions of the tongue may be 
the first indication of a nocturnal epileptic attack. 

There is an extremely painful condition of the tongue, due to 
a papillitis, in which nothing abnormal can be found on the sur- 
face; but, on magnification, small, ulcerating points are seen 
hidden in the folds of the mucosa about the fungiform papillae 
of the tip and the margin of the tongue. 

Moeller's glossitis, or chronic superficial glossitis, is charac- 
terized by bright red lines or patches at the margin or tip. The 
pain, which is the principal lesion, is out of all proportion to the 
local involvement, and is much increased in chewing and speak- 

According to Kiesman (113b), pain in the tongue (glosso- 
dynia) which arises without any apparent organic lesion, may be 
divided into the following, which is the classification of Chaveau 

(1) Glossodynia secondary to trigeminal neuralgia, especially 
the inferior dental branch of the trigeminal. 

(2) Glossodynia of the insane, starting as a local paresthesia. 

(3) Glossodynia of tabes, corresponding to crisis in other 

(4) Glossodynia of hysteria. 

(5) Rheumatism of the lingual muscles, or rheumatic glosso- 

(6) Glossodynia due to local causes. These may be classified 
into the extrinsic and intrinsic. The extrinsic causes are: (a) 
dental affections and artificial teeth, and (&) granular pharyngitis 
and hypertrophy of the posterior pillars and of the lingual tonsil. 
Among the intrinsic causes are: (a) lingual varices; (&) chronic 
glossitis from tobacco, alcohol, spices, iodin, lead or gout, and (c) 
papillary hypertrophy of the follicular region of the tongue. 

Reference Areas in Diseases of the Tongue. — Disease of the 
anterior portion causes pain to be referred to the mental area ; 
of the lateral portion, to the hyoid area ; of the dorsum, to the 
superior laryngeal and the occipital area (Head). 

Salivary Glands. — The salivary glands are subject to the ordi- 


nary glandular pain-producing diseases, as inflammation, etc. 
There may be present also, in the ducts of the glands, some ob- 
struction which gives rise to an intermittent colic with an asso- 
ciated swelling and tumefaction of the gland. This condition 
may sometimes be diagnosed by running the finger along the 
course of the ducts, when an obstruction, if present, generally 
may be felt. The most common form of obstruction is a salivary 
calculus (Ranulus). The parotid gland sometimes becomes in- 
flamed, and is very painful, giving rise to the entity called 
"mumps." It also becomes tender after oophorectomy, and in some 
cases where orchitis is present. Pain beneath the angle of the j aws, 
in those who are convalescent from typhoid, should always lead 
to investigation of the parotid as the possible cause of the pain. 

Pharynx and Tonsils. — Pain in the pharynx may be present, 
either objectively, on swallowing, or subjectively, without any 
provocative act. In the first case we find that the causative 
factors are slight, such as small ulcers and superficial inflamma- 
tions ; but when the infectious agents extend deeper, and the 
surrounding connective tissues are involved, the pain is felt with- 
out any exciting productive factor, and is continuous. This is 
well exemplified in parenchymatous tonsillitis, in which the pain 
extends to the angles of the jaws, also to the ears, even down the 
neck, and in phlegmonous pharyngitis, which is extremely pain- 
ful, there being a constant burning or aching pain, which in some 
cases assumes a throbbing character. In the latter, the pain may 
be of such magnitude that the patient lives a miserable existence, 
being unable to eat or to sleep until the abscess which has formed 
ruptures and relieves the pressure. 

The tonsils and posterior pharyngeal wall may be extremely 
tender in certain forms of streptococcic sore throat, and the pain 
often persists for a long period after the cessation of the acute 

A so-called gouty throat causes a' similar painful condition of 
the pharynx and tonsils. There are few signs of inflammation; 
the mucous membrane, however, is lax and edematous. 

Various types of pharyngitis, granular, follicular, etc., cause 


pain. The diagnosis depends upon a special knowledge of the 
various pictures. All of these conditions cause a certain amount 
of referred pain. The pain in front of the ear, complained of so 
much by patients with tonsillar affections, or by those who have 
some tonsillar traumatism, operative or otherwise, is in the hyoid 
reference area of Head (for which, see Fig. 60, p. 291). The 
pain may also be referred to an area in the neck in the submaxil- 
lary triangle. Palpation here will disclose an enlarged gland. 

Esophagus. — The esophagus below the cricoid cartilage was 
formerly considered to be non-responsive to tactile and other stim- 
uli, but now it is known to be sensitive to heat, cold, tactile and 
chemical stimuli, and it is also held that many apparent stomach 
sensibilities are, in reality, esophageal sensibilities. Inflamma- 
tion of the esophagus is, if severe, productive of considerable 
pain. The pain is of a deep, burning character, and is felt 
along the course of the esophagus. Pain is also felt on move- 
ment of the esophagus, which occurs when the head is bent for- 
ward or backward, and is also present when external pressure is 
made through the overlying tissues upon the esophagus. Pain on 
swallowing is very severe. In the severest cases of corrosive 
esophagitis there may be no pain. 

Pain felt in the esophagus, without any objective lesion, may 
be due either to a hyperesthesia or a paresthesia. In the former, 
pain is produced by factors which cause irritation, such as in- 
flammation of the esophagus, or a neuritis of the nerves supplying 
it. The latter (neuritis) gives rise to a perversion of sensation; 
for instance, the act of swallowing, which ordinarily gives rise 
to no sensation, is, in this condition, interpreted as painful. In 
stenosis of the esophagus pain, as a rule, is absent. In cancer of 
the esophagus there may be only a feeling of distress or of dis- 
comfort under the sternum, generally localized to the area of the 
growth. Sometimes severe pains, conflned to the area of the 
growth, or referred to the region of the xiphoid cartilage, may 
also be present. They generally are of a '^tearing, piercing char- 
acter, and radiate widely to the back, neck, or shoulders." They 
accompany the deglutition of food, but may be independent of it, 


and are often nocturnal. Though generally present only late in 
the disease they may be the earliest manifestations of it 

Referred pains may he present in the intercostal spaces be- 
tween the shoulder blades, in the epigastrium, in the throat and 
head, in the ear, or in the extremities (Rosenheim). 

Dyspnea and attacks of pain resembling angina pectoris also 
occur. These are due to pressure on the trachea or upon both re- 
current laryngeal nerves. 

Localization within the esophagus is fairly accurate; Lamy, 
in his study of one hundred and thirty-four cases of carcinoma of 
the esophagus, found that four-fifths of the patients were able 
to locate the lesion within an inch or two of the correct site; but 
in the remainder a correct localization was impossible ; often a 
carcinoma of the lower third would be located by the pain-sensa- 
tions in the upper third, or vice versa. Obstruction gives rise 
to sensations for the most part in the middle line, deeply seated, 
beneath the sternum, or, if the obstruction is low down, in the 



After the review of the pain-producing diseases which are 
located in the alimentary passages leading to the stomach, it is 
next in order to consider the pains and pain-prodncing disorders 
of the stomach. Of late years there has been considerable contro- 
versy as to whether the stomach has pain-sensation or not. The 
weight of the argument seems to be on the side of those who 
claim that it has not. It is claimed that the sensations which are 
felt in disease of the alimentary viscera are bnt referred sensa- 
tions or impulses, carried to the cord in the sympathetic path- 
ways, and thence referred again to the periphery through the 
cerebrospinal nerves. 

From the researches of Hertz in particular it would appear 
that the gastric mucosa does not respond to tactile nor to chemi- 
cal stimuli by pain. The stomach mucosa does not register 
thermal stimuli, and the sense of warmth and coolness following 
the ingestion of hot or cold liquids is largely due to the sensi- 
bility of the esophagiis to these forms of stimuli. The sensation 
of fulness in the stomach is due to the deep-pressure sensibility of 
the muscular coat, and is brought about by tension. 

The sensation of hunger and emptiness is largely a matter of 
habit, associated with malaise and weakness. It is conditioned 
by the disturbance in the periodicity of the muscular hypertonus 
and of neuronic excitability, normally the result of regiilar eat- 


^According to W. B. Cannon and A. L. Wasliburn (Amer. Jour, of Phy- 
siology, March, 1912, Vol. XXIX, p. 455), hunger is due to the contraction 
not only of the stomach, but also of the lower part of the esophagus and the 
intestines. They were able to prove a relationship between rhythmic contrac- 
tions of these organs and pain sensations. 




However, even though pain in the stomach is not, as a rule, 
regarded as true visceral pain, yet it is closely related to it, for it 
may be due to the tension already spoken of or to the spread of the 
disease to surrounding sensitive structures, or to the traction of the 
peritoneal connections. The accompanying tenderness is most 
often due to hyperalgesia of the skin, voluntary muscles and con- 
nective tissues supplied by that segment of the spinal cord w^hich 
receives the incoming stimuli from the stomach itself and its con- 
tiguous structures. 


The areas to which the pain of stomach disorders are re- 
ferred are, first, the epigastrium, and (in many cases) the back, 
in an area which, according to Cumiston and Maylard, is between 
the posterior borders of both scapulse and opposite the spinous 

Fig. 89. — Areas of Referred Pain as Given by Head. 

A. One of the commonest situations for pain. 

B. One of the commonest sites of gastric pain. 

C. Maylard gives this point opposite the 5th dorsal spine as one of the 

commonest locations of gastric pain. 

process of the fifth dorsal vertebra. The pain also often circles 
around from one of these areas to the other, and they are often 
tender to the touch. The area spoken of by Cumiston and May- 
lard as opposite the fifth dorsal spine is given by other authori- 
ties as opposite the ninth or tenth dorsal spine. This agrees with 



mj own observations and coincides more closely with the deduc- 
tions of Head, who places the maximum points of tenderness in 
the seventh or eighth dorsal segments, opposite the ninth and 
tenth dorsal spines. Boas, on the other hand, locates the area 
of maximum tenderness as opposite the eleventh and twelfth dor- 
sal spines. When pain is produced in stomach disorders, it may 
be felt in any of the areas supplied by the seventh, eighth, or 
ninth dorsal segments, but it is more apt to be felt, and felt 










FiG. 90 — Nekvous Supply of the Stomach. 

more severely, in the maximal points of tenderness of these 

In the accompanying drawing is shown the nerve supply to 
the stomach. It is seen to be both sympathetic (splanchnic, celiac 
ganglion) and cerebrospinal (vagus). True visceral pain is con- 
veyed through the vagus, but it is of the deep-pressure sensibility 
(tension) type allied to Head's protopathic system. 

The areas of tenderness are of great diagnostic significance. 
The hyperalgesic areas (Head) affected in stomach diseases are 
the seventh, eighth, and ninth dorsal. The seventh and ninth 
areas are those most frequently aifected. The upper one, the 
seventh dorsal, seems to be associated particularly with the stom- 
ach diseases causing vomiting. When it appears, as a sequel to 
vomiting, it is frequently accompanied by pain in the area 
next to and above it, namely, the sixth dorsal. The sixth dorsal 
area is associated with disease in the lower part of the esophagus ; 


consequently, when both the sixth and seventh areas are affected 
the disease is somewhere near to and probably involves the esopha- 
gus. In the same way the ninth dorsal area is shared by both 
the stomach and the intestines, and when both are affected the 
lesion is probably in the neighborhood of the pylorus. When the 
seventh dorsal is involved, the pain, as a rule, comes on within 
half an hour after taking food; while, if the eighth dorsal is in' 
volved, the pain generally comes on at least an hour later. 

By stimulating the area in the hypogastrium, which is hyper- 
algesic, a reflex contraction of the upper segment of the recti 
takes place. While in some cases only a segment, in others the 
entire rectus is thrown into contraction. 

That the area in which pain is felt in stomach diseases does 
not necessarily correspond to the site of the gastric lesion, may be 
seen from the drawing (Fig. 98), where the projected outline of 
the stomach is shown, with the dark circle indicating the area 
of tenderness in gastric ulcer, the tenderness in no ease being 
directly over the stomach. 


When pain occurs in the gastric areas, it is necessary to in- 
quire into the following : (1) the character of the pain; (2) the 
time and manner of its appearance; (3) its relation, if any, to 
the ingestion of food; (4) the duration of the pain; and (5) pre- 
vious attacks. 

Character of Gastric Pain. — Certain types of gastric lesions 
have characteristic pains ; for instance, that of gastritis is burn- 
ing; that of spasm of the pylorus is sharp and sudden; that of 
ulcer is very severe and is sharply circumscribed; that of per- 
foration is sharp and agonizing, and quickly spreads from the 
site of its original location; that of acute dilatation is severe 
and constant, and is accompanied by symptoms of collapse. 

It should also be borne in mind that the severity of the pain 
has no proportionate relation to the gastric conditions, but often, as 
in pain caused by lesions in other organs, depends upon the 


susceptibility of the nervous system and the sensitiveness of the 
pain-receptive centers of the individual patient. 

Time and Manner of Its Appearance. — Should the onset he 
sudden, vlthout any apparent exciting factor and without any 
previous history of pain, perforating ulcer or pyloric spasm is 
to be considered. In perforating ulcer associated symptoms of 
collapse and spreading peritonitis, with a diffusion and constant 
increase of the pain, would be present, while in pyloric spasm 
irregular paroxysmal pains that are sharply localized with no 
tendency to spread or to become generalized would be present. 

Acute gastritis is associated with the vomiting of indigestible 
or fermenting substances ; this generally tells the tale. If the 
pain is of slow onset, and there are at first discomfort, and 
then a gradually increasing distress until well-marked pain is 
present, particularly if the pain is associated with the vomiting 
of blood (coffee-ground vomitus), it is necessary to examine 
for gastric carcinoma. 

Relationship to Ingestion of Food. — If the pain comes on at 
a definite time after eating, and is relieved by vomiting, gastric 
ulcer is thought of. If it comes on immediately after eating, the 
cardiac end is affected; on the other hand, if it does not appear 
for an hour or two after eating, ulcer of the pylorus is to be con- 
sidered. If, instead of coming on immediately, it makes its ap- 
pearance one-half to two hours after eating, carcinoma or hyper- 
chlorhydria should be considered. In carcinoma the coffee- 
ground vomit is distinctive, while in hyperchlorhydria the excess 
of hydrochloric acid, with the absence of blood, is sufficient to 
make a diagnosis. In early carcinoma, pain and coffee-ground 
vomit are absent. Hyperchlorhydria may occur from gall-blad- 
der disease, duodenal ulcer, or be purely functional. 

Duration of Pain. — The duration of the pain in any of the 
gastric disorders is variable. It seems to be present more con- 
stantly and for a greater length of time in those disorders which 
have an organic basis for their production. In carcinoma the 
pain is steady and persistent, while in hyperchlorhydria and 
pyloric spasm it is associated with the ingestion of food. 


Previous Attacks. — A. history of previous attacks of pain may 
be of value, in that it often is confirmative of the diagnosis which 
the present symj^toms would suggest. 

Associated Symptoms. — Constipation is generally associated 
with gastric ulcer, hyperacidity, and carcinoma. 

Pain Reflected or Referred to Gastric Areas. — ^When pain is 
present in the gastric areas, it may be not of gastric but of 
nervous origin (intercostal neuralgia) ; or it may be projected from 
the cord (locomotor ataxia, general paralysis, disseminated scle- 
rosis), or it may be a reflex from other organs, as the uterus, kid- 
ney, intestines, appendix, gall-bladder, pancreas, heart, or prostate. 


The commoner lesions of the stomach causing pain are: (1) 
displacement; (2) gastralgia; (3) hyperchlorhydria ; (4) cardiac 
or pyloric spasm; (5) acute dilatation; (6) acute gastritis; (7) 
chronic gastritis; (8) gastric erosions; (9) gastric ulcers; (10) 
perforating ulcer; (11) new growths, and (12) perigastric ad- 

Displacement of the stomach (gastroptosis) generally causes 
no pain until it induces a dilatation. Then the sensation 
produced is rather a disagreeable, nauseating feeling than 
a true pain. It is increased by eating or by standing, and is 
decreased on lying down or on supporting the abdomen by a 
bandage judiciously applied. 

Gastralgia or Gastromyalgia. — By many gastralgia is dis- 
claimed as a, misnomer, because it is said that there is no such 
pathological entity. But why? The stomach is an organ whose 
walls consist of muscular tissue, and why should not this tissue, 
even though it is involuntary, be subject to the same metabolic 
disturbances as are the muscles of the back, which under abnor- 
mal metabolic changes give rise to lumbago ? The only differ- 
ence is that in the affected back muscle the changes act princi- 
pally on the terminations of sensory nerves in the muscles, while 
in the stomach walls the nerve terminals affected are not sensitive 
in the meaning that they convey pain or touch sensation. There- 


fore, for this irritation to be perceived as harmful, that is, painful, 
it must be carried to the cord, where, irritating some sensorj 
neuron, the stimulus is carried to the brain, where it is perceived 
as coming from the area of distribution of this neuron. That such 
a changed metabolic and at the same time pain-producing lesion 
may exist in the stomach is in accord with the opinion of the 
majority of observers. The condition, instead of being termed 
gastralgia, which is only a general term, should be called gastro- 
myalgia, although the term gastralgia is still in general use. 

Schmidt claims that "the existence of true gastralgia result- 
ing from purely anatomical and functional disturbances is as cer- 
tain as the pain of dental caries." Maylard describes it as "oc- 
curring generally in those of a neurotic taint; and the pain may 
be of the most excruciating character, seizing the patient in the 
epigastrium, and striking through to the back, radiating some- 
times round the chest or waist." It is most erratic in the time of 
its appearance. Sometimes it follows the ingestion of food, while 
at other times it appears without any known cause. It may 
sometimes appear periodically at night, and at other times it may 
follow upon any excessive draft upon the nervous system by 
worry or excitement. The pain is "generally out of all proportion 
to other physical symptoms of any suggestive physical disease. 
The patient may also complain of a beating sensation, pulsating 
sensation, a feeling of heat or cold. Periods of pain generally 
alternate with periods of complete freedom from it."^ 

The symptoms usually associated with this condition are flatu- 

^ This consideration of the subject differs markedly from that given by 
Schmidt, who classifies all gastralgias as neuralgic in origin. While it must be 
admitted that stomach pain depends upon the irritation of nerve terminal fila- 
ments for its production, yet, as mentioned above, in a somewhat though not 
entirely similar condition in the voluntary muscles, the term myalgia is used. 
It seems that an analogous term, such as gastromyalgia, should be used for 
pain having its origin in the stomach musculature. The general term gastral- 
gia, therefore, is ill-fitted, and is only to be used in a general way to include 
those pains originating in the stomach, the etiology of which cannot be defi- 
nitely determined. 

On the other hand, neuralgia of the stomach is entirely different in its 
etiology from gastromyalgia, but is included, as are all stomach-productive 
pains of unknown etiology, under the generic term ' ' gastralgia, ' ' 


lence, distention, anorexia, cravings for food, vomiting, and py- 
rosis. The stomach pains frequently alternate with attacks of 
migraine (same as in angina pectoris), neuralgia of the head, and 
asthma. Women are more prone to gastromyalgia than men, in 
the proportion of two to one, and it is most common between the 
ages of twenty and forty-five. 

In an entirely different class, but slightly related to the 
pains we have just described, are those due either to a secretory 
or a motor disturbance. These will be considered later under 
their proper headings. In the meantime it is well to remem- 
ber, in considering the cause of stomach pain, that the lessened 
resistance of the nervous system to pain-production is of mani- 
fest importance. Some people, owing to disease or inherited pre- 
disposition, are abnormally sensitive to pain, so that the percep- 
tion of sensations, which in others ordinarily would not even be 
disagreeable, would be felt by them as sensations varying all the 
way from distress to actual pain. In this connection it is helpful 
to know that gastric pains not of purely nervous origin are influ- 
enced by the ingestion of food and the position of the patient, while 
those of purely nervous origin are not. 

The diseases acting as predisposing causes of gastromyalgia 
or gastroneuralgia are about the same as those which cause a 
lessened resistance in the nervous system, and which are pro- 
ductive of cerebrospinal neuralgia. Among them may be men- 
tioned anemia (chlorosis), infectious diseases, rheumatism, syph- 
ilis, influenza, tuberculosis, excessive use of stimulants (alcohol, 
tea), sexual over-indulgence, gout, diabetes, uremia, and physical 

The reflexes which are sometimes felt as pain in the gastric 
reference area, and which in some cases are even accompanied 
by vomiting, will be considered under the reflex pains of the appro- 
priate viscera, though for clearness of conception they will also 
be described in our consideration of the diagnosis of stomach 
pains. These reflex pains in the epigastrium, associated with 
vomiting are due to disease of the gall-bladder, pancreas, appen- 
dix, uterus and appendages, etc., should not, as is done by some 


authors, be placed under gastralgia, but should be considered 
under the lesions of the different organs producing them. This 
is sometimes very difficult, for, in many cases, it is not easy to 
distinguish the origin of the different pains ; for instance, gall- 
stone colic is often confused with gastric pain, yet it may be dis- 
tinguished from it by its paroxysmal character, its tendency to 
become localized to the right and to extend around the right side 
to the area underneath the right scapula. At the same time it is 
associated with localized gall-bladder tenderness, and often there is 
a well-marked enlargement of the gall-bladder and sometimes a 
generalized jaundice. Angina pectoris has also been confused with 
gastric pain. Here the pain, as a rule, follows exertion, and radi- 
ates into the left arm and hand. The heart may be tumultuous in 
action, and frequently there are severe depression and a fear of 
death. The appendix, also, has in many cases been found to 
cause epigastric pains; but here epigastric pain, with no tender- 
ness over the epigastrium, but over the appendiceal region, is 
present. There may also be a palpable mass in the same region, 
and the pain and tumor are associated with vomiting, eructation 
of gas and constipation. Of diagnostic importance in differenti- 
ating pain of local origin from referred pain is the administra- 
tion of local anodynes, as cocain, alypin, menthol, and phenol. 
These generally cause the pain to lessen or cease when it is of 
local irritative origin, such as occurs when the lesion is in the 
mucous membrane, namely, in ulcer, carcinoma, etc. When no 
effect is noticed, after the administration of the local anodyne, 
neurotic lesions should be considered. Of considerable diag- 
nostic importance is the fact that gastromyalgia is frequently 
relieved by pressure. 

Hyperchlorhydria. — Hyperchlorhydria is the only secretory 
neurosis of the stomach which produces pain. This pain comes 
on one-half to two hours after eating, and lasts a few hours, or 
until more food is taken, being particularly relieved by the in- 
gestion of proteids, and also by alkalies. It is much less after 
large meals, especially those containing much meat and eggs and 
deficient in carbohydrates. The pain differs from that due to 



gastric ulcer in being diffuse and extending over the entire abdo- 
men. It seems to be frequent in persons of neurotic tempera- 
ment, and is commonly associated with gall-stones. Hyper- 
chlorhydria is also frequently associated with neurotic motor 
disturbances. The pain produced by it often is accompanied by 

This substernal pain represents the 
esophageal component of the pain 

f Tenderness on deep 
\ pressure 

'Area of hyperalgesia to 
pin point pressure. 
Over this area there is 
also pain to deep pres- 
sure. It lies about the 
junction of the 7th left 
costal cartilage with the 
7th rib 

Fig. 91. — Location of the Pain Symptoms in a Case of Hyperchlor- 


a considerable belching of gas, generally preceded by a burning 
sort of pain, which seems to run up under the sternum to the 
throat, and is accompanied by the regurgitation of acid-tasting 
fluid. The pain may also radiate to the back, to the axilla, and 
to the scapula. In some instances the pain seems to be due to 
the presence, even in small quantities, of hydrochloric acid. In 
these patients there is a peculiar antipathy of the stomach to the 
presence of any acid. The examination of the stomach contents 
often shows a normal or even a subnormal percentage of acid. 

Hertz has shown that the gastric mucosa is not painfully 
stimulated by excess of hydrochloric or other weak acids. It is 
probable that the heartburn of so-called hyperchlorhydria has 
nothing whatever to do with acid production, and that the term 
is a misnomer. The hot sensation is closely related to that felt 
following the ingestion of alcohol, and is felt most often following 
slight regTirgitation due to the presence of excessive amounts of 
gas. Hertz maintains that heartburn is an esoj)hageal sensation, 



not a gastric one, and is due to the stimulus of excessive carbo- 
hydrate fermentation (hot bread — biscuit — causing the so-called 
pudding heartburns). This causes the production of alcohols, 
ethers, and organic acid in the stomach, which bj regurgitation 

Fig. 92. — Pain Radiation. 

Crosses indicate the sites of pain and the Unas -with arrows indicate the 

direction of the pain radiation. 

act upon the lower end of the esophagus, thus giving rise to the 
classical heartburn erroneously interpreted as a hyperchlorhydria. . 
For a further interpretation of the causes of pain in hyperchlor- 
hydria, see gastric ulcer. 

Pyloric or Cardiospasm. — The stomach resembles other divi- 
sions of the hollow abdominal viscera in that it is subject to colic; 
but the parts chiefly affected are the pylorus and the cardia, as 
the intervening portion has so great a lumen that it contracts en 
bloc less readily. Then, too, this part of the stomach is so situated, 
and its attachments to the adjacent viscera are so arranged, that it 
may undergo considerable distention without any symptoms being 
produced ; but as soon as the distention becomes excessive and trac- 
tion is made on its peritoneal and diaphragmatic attachments, 
pain results. The same is true, when, owing to the contraction 
of the pylorus or cardia, a change in the relationship of these two 
parts to the surrounding viscera results, and a pull on their peri- 
toneal attachments occurs. 


Bj reference to the anatomy it is seen liow the cardia of the 
stomach is immediately below the opening in the diaphragm, and 
how, when it contracts, especially when the stomach is full, there 
must be a stretching of the gastrophrenic ligament, with resulting 
pain. The same is true of the pylorus, but here the pull is made 
on the gastrohepatic omentum, and possibly also on the gastro- 
colic omentum. Hertz claims that the pains in pyloric or cardiac 
spasm are really tension pains, due to distention of a segment 
of the stomach. In pyloric spasm a persisting contraction of the 
pylorus occurs as a reflex from the presence of an excess of HCl 
in the stomach. The peristaltic wave in the stomach, being ex- 
cessive from the HCl stimulation, pushes the food onward until 
it reaches the prepyloric part of the stomach ; from here, owing 
to the closure of the pylorus, it cannot advance further, and 
tension is made upon the stomach walls at this point. 

From this it would seem that not only is the small part of the 
stomach at the pylorus involved, but that also a large part, if not 
the entire stomach musculature, is involved in the contraction. It 
is hardly probable that the contraction of the constricted part of 
the bowel at the pylorus could so alter the relationship of this one 
part to the gastrohepatic or gastrocolic omentum that the stretching 
of it would be great enough to cause the severe and widely diffused 
epigastric pain which is sometimes present. Another argument in 
favor of the participation of the muscular wall is that the pain is 
relieved by vomiting. 

A somewhat similar cause exists for the pain in hour-glass 
stomach. Here a portion of the stomach is contracted, and an hour- 
glass stomach results. The food entering the upper compartment 
is pushed forward by the peristaltic waves until it reaches the place 
of contraction; here it is unable to progress further, and at this 
point tension is made on the gastric walls, and pain results. As 
would be expected, the pain is not felt when the stomach is empty, 
but results only after ingestion of food and drink. It is relieved 
by vomiting. 

The cause of pain in cardiosj^asm is the dilatation of the ter- 


minal portion of the esophagus. This is the result of stasis of 
food, due to spasmodic closure of the cardiac sphincter. In cardio- 
spasm the pain comes on immediately after eating, is fairly con- 
stant, and seems to be located beneath the costal margin at the left 
seventh costal cartilage, while in pyloric spasm the pain is localized 
in the midline, about midway between the umbilicus and ensiform, 
and comes on two or three hours after eating, i. e., at the time of the 
passage of the gastric contents through the pyloric opening. Both 
pains have a typical paroxysmal gripping or twisting character, 
and are equally severe. The pyloric spasm generally is relieved 
by vomiting, while cardiospasm gradually passes off, no vomiting, 
as a rule, occurring. In both midnight attacks are very frequent. 
It seems also that in some cases the contraction of the cardiac and 
pyloric sphincters alone can cause reflected pain, this pain being 
due to the unusual squeezing of the nerve terminals in the muscular 
tissue, the result of the abnormally severe contraction. For the 
production of pyloric spasm pain it is not always necessary that 
the stomach be full, for in many cases when it is empty the irrita- 
tion of the gastric secretions (which in this condition are often 
highly acid) will produce it. Also, it can be relieved by washing 
out the stomach. 

A similar contraction of the musculature of the pylorus and, 
in some cases, of the entire stomach and duodenum is the cause 
of hunger-pain. This differs from cardia and pyloric spasm in 
that it can be relieved by the ingestion of food, provided the 
stomach mucosa and musculature are intact. The ingestion of 
food will not relieve the associated hunger-pain present in ulcer 
or carcinoma of the stomach, because the food, of itself, is an irri- 
tant in such conditions, and aggravates instead of easing the 

In all these conditions, after the pyloric spasm has persisted 
for some time, a dilatation of the stomach results. This dilata- 
tion, in turn, causes gastric pain, because of the traction and 
pull of the gastric walls on the omental attachments. The pain 
is of the same kind as described in acute dilatation of the stom- 


ach, only in dilatation the result of pyloric spasm the pain is 
added to the previously existing spasm pain. In acute dilatation 
also, the pain is more generalized, and becomes constant, while the 
pyloric-spasm pain is paroxysmal. In case of dilatation of the 
stomach the epigastrium is distended, the outlines of the stom- 
ach are plain, and visible gastric peristalsis can be seen; also, 
on listening, borborygmi and bubbling noises can be heard, 
Succussion sometimes gives rise to a splashing sound. Eructa- 
tions of sour-tasting fluid are also present. These associated 
symptoms generally come on when the pain is most severe. If 
vomiting occurs, and the spasm has been of some duration, 
large quantities of gastric contents are expelled. Sometimes 
the attacks of colic are accompanied by a mild chill of 
nervous origin, elevation of the temperature being entirely 

Pressure on the distended stomach is well borne, and is fre- 
quently applied by the patient, because it seems to aid in the forc- 
ing on of the stagnated stomach contents. The pain is increased 
by the eating of indigestible foods. According to Schmidt, cold 
applications to the epigastrium seem to be better borne than hot 
ones, and to be more beneficial to the patient. 

Acute Dilatation of the Stomach. — Acute dilatation of the 
stomach frequently is a cause of the most severe pain. It is prone 
to occur after operations, especially those in which there has been 
considerable handling of the abdominal viscera. It comes on, 
as a rule, three or four days following the operation. By many 
it is held to be Only a symptom of a peritonitis, which, it is 
claimed, is present in every case of such vomiting. At first there 
is a feeling of distress in the epigastrium, which soon increases 
until severe pain is felt. This is generally accompanied by the 
vomiting- of a greenish fluid, and by a gradual abdominal disten- 
tion, with rise of pulse rate, and signs of severe systemic distress. 
This state, unless relieved, is rapidly fatal. Acute dilatation also 
occurs in many patients who have not been subjected to operative 
interference, but generally it is not of as severe a form as in the 


operative ones. In both of these conditions the pain is of a diffuse 
nature, and is located in the epigastrium. Because of the acid con- 
dition of the stomach contents, the pain may be partially relieved 
by the ingestion of alkalies; but the only sure relief is from re- 
peated stomach washing. Should stomach distention be suspected, 
it can be confirmed or disproved by percussion and palpation, as 
well as by the stomach tube, by which, if gastric dilatation is 
present, large quantities of greenish fluid may be removed. 

In some cases distention of the stomach may be associated 
with distention of the duodenum, and, when this occurs, as in a 
case reported by Torrance (57Y), there may be pain under the 
right shoulder and over the eighth and ninth ribs to the right of 
the spinal column. 

The pain of gastric dilatation is also partially due to the trac- 
tion which the diaphragm exerts on its costal attachments, owing 
to the upward force exerted upon it and its consequent displace- 
ment by the distended stomach. 

Acute Gastritis. — Although the stomach has no special tactile 
sensory nerves, it reacts painfully to inflammatory lesions. 
When inflammation is present in the stomach walls, the adjacent 
lymphatics become involved, lymphangitis results, and this in- 
flammation spreads to the parietal peritoneum through the im- 
mediate attachments, and causes it to become hypersensitive. At 
the same time the inflammation of its walls causes the stomach 
to become very irritable, and to react much more strongly than 
usual to stimuli; so that, on the entrance of food and drink, it 
contracts to a greater than normal degree. This produces trac- 
tion much greater than normal on the inflamed mesentery, and at 
the same time causes tension within its own muscular coat and 
pressure upon the nerves of deep sensibility with resultant pain. 

In gastritis the subjective pain is felt in the epigastrium, and 
at the same time the gastric areas of hyperalgesia (Head) may 
be present. The subjective pain is of a dull, aching character, 
increasing to a sharp, burning on the ingestion of foods. Another 
characteristic of this pain is that it seems to run directly through 



to tlie back, this being most probably the result of the irritation 
of the inflamed peritoneum around the cardiac opening, which 
lies very much closer to the back than it does to the anterior 
abdominal wall. On making pressure over the epigastrium, pain 
is elicited; light pressure bringing out, in many cases, the hyper- 

rPain in epigastrium goes 

directly through to the 

-^ back. Pain between 

shoulders is also some- 

(^ times present 

Fig, 93. — Figure Illustrating the Location of Pain in Acute Gastritis. 

algesic areas of Head, while deep pressure brings to light the 
tenderness of the subserous peritoneum, which, because of its 
lymphatics, is frequently involved in the inflammatory process. 
This pain varies in intensity and seems to have some relationship 
with the severity of its lesion, so that the extent of the gastric 
inflammation may partially be judged from the magnitude of the 

The pain of acute gastritis is fairly sudden in its onset. It 
may follow a night of alcoholic indulgences, or occur after the 
eating of indigestible substances, and is associated with nausea 
and vomiting. It may be so severe that morphin is required to 
relieve it. In some cases there are an elevation of the tempera- 
ture as high as 104 ° F. and an increased rapidity of the pulse. 
The recti muscles of the upper abdomen are also contracted, espe- 
cially on the left side, and are slightly tender on palpation. 


Chronic Gastritis. — Chronic gastritis is generally not painful, 
though after eating there may be a feeling of discomfort. Rie- 
gel, according to Gilbride, claims that in the atrophic forms of 
gastritis the pain resembles that of the gastric crisis of tabes. 

Gastric Erosions. — Gastric erosions, as pathological entities, 
occupy a position intermediate to gastritis and ulcer. Pathologi- 
cally they are less extensive than ulcers, and more intensive than 
gastritis. The pain produced is of a dull aching character, and 
seems to extend throughout the entire stomach area. It is not 
affected by pressure or by change of position. It generally comes 
on after eating, persists an hour or two, and then gradually sub- 
sides; but it may be present irrespective of the intake of food, 
and intervals may be present in which there is absolutely no pain. 
The course of the disease is prolonged. Emaciation, loss of appe- 
tite, and, in many cases, hematemesis may result. 

Gastric Ulcer. — Gastric ulcer, in its pain production, depends 
upon practically the same factors as does gastritis. The lesion 
in ulcer is circumscribed, while that of gastritis is diffuse. Both 
are associated with lymphangitis, and it is this lymphangitis 
which contributes greatly to the pain that is produced. That the 
pain and tenderness which are felt on palpation are not present in 
the stomach but in the abdominal wall can be demonstrated from 
the following premises: 

(1) The ulcer, in most cases, is on the posterior wall of the 
stomach, and pressure upon it through the abdominal wall, rigid 
because of the contraction of the rectus, is almost impossible. 

(2) The pain and tenderness are constant, while the relative 
position of the ulcer is always varying, depending upon move- 
ment of the stomach due to respiration, peristalsis, distention 
with food, liquids, gas, etc. 

(3) On exposure of the stomach by exploratory laparotomy 
the ulcer may not be found immediately beneath the area in which 
the pain and tenderness had been felt. 

In the following drawing, Mackenzie (586) illustrates the 
relative position of the pain and the site of the ulcer. In his 



cases the site of the ulcer bore no relationship to the site of the 
pain; but when the ulcer was near the cardiac end of the stom- 
ach the localized pain and the cutaneous and muscular hyperal- 
gesia were situated high in the epigastrium, while if the ulcer 
was situated near to the pylorus 
it caused pain low down in the 
epigastric region. 

It is claimed that in some 
cases it is the contraction of the 
pylorus which causes pain; in 
others that it is the contraction 
of the bundle of fibers which 
surrounds the prepyloric region 
of the stomach and separates the 
antrum pylori from the rest. In 
one case Moullin reports a cure 
from the ulcerated condition 
and the pain by section of these 
fibers (Mansell Moullin, 578). 

In this case neither ulcer 
nor scar could be found when 
the stomach was opened, so that 
it was probably only a case of 
hypertrophied pylorus. 

That the pain in gastric 
ulcer is not due to hyperacidity of the stomach contents can be de- 
duced from the fact that increase in the hyperacidity, due to the 
ingestion of acids, produces no increase in the pain. It has also 
been shown that pain cannot be produced by irritation of the nor- 
mal mucous surface of the stomach. The researches of Hertz also 
tend to show that an ulcerated surface is insensitive to acids in the 
strength found in the stomach. 

In some patients an ulcer of the stomach causes no pain. 
When this occurs the ulcer is generally situated on the anterior 
surface, near to the cardia, no adhesions having formed between 
it and the parietal peritoneum. C. W. Habershon, in 1859, wag 



94. — -Location of Pain 
Gastric Ulcer. 
In the figure the area A shows the 
area of pain when the ulcer was 
at the cardiac end of the stomach 
a; B when the ulcer was in the 
middle of the lesser curvature b; 
C when the ulcer was at the 
pylorus c. 


one of the first to show that ulcer confined to the mucous mem- 
brane alone was not painful. He likewise claimed that cancer 
and other diseases, while restricted to the mucous membrane, 
produce no pain. 

The pain of gastric ulcer can generally be distinguished be- 
cause of its several characteristics, as follows : 

(1) Time of Onset. — Pain generally begins immediately on 
the entrance of food into the stomach, and gradually increases 
until it reaches a climax (at the time the pyloric end is at work), 
and then, as the stomach empties itself, it becomes less and less, 
and gradually disappears. It is also relieved by vomiting, and 
in many cases by the ingestion of alkalies. After an hour or two 
it ceases. The longer the interval between the time of ingestion 
of food and the appearance of the pain, the farther away from 
the cardia and the nearer to the pylorus is the ulcer. If it has 
occurred immediately after eating, the ulcer is probably near 
the cardiac orifice or the lesser curvature; if two or three hours 
after, it will be at the pylorus ; and, if four hours after, and 
relief ensues on taking food, the ulcer is probably in the duo- 

(2) Character. — The pain, as a rule, is of a dull, boring char- 
acter, and is generally localized to a small area in the epigastrium. 
It may radiate to the back. Sometimes, instead of a pain, there 
is present in the epigastrium a dull, disagreeable, constant sensa- 
tion. When this is present, adhesions, peritonitis, and increased 
continuous secretion of gastric juices are likely to be found. The 
statement that the ulcer can be mapped out by percussion is mani- 
festly absurd, as can readily be understood from a study of the 
origin and propagation of gastric pain. A peculiarity worth 
noting is that the pain is most severe when the ulcer is located 
on the posterior surface, because, in this location, it is nearer to 
the parietal peritoneum, upon which there is more drag than 
would occur if the ulcer was situated upon the anterior surface. 
In some cases there may be a burning sensation after eating, and 
the pain may radiate to the sides of the chest and shoulder. The 
sensation varies from a feeling of distress, that is hardly notice- 


able, to a pain of the greatest severity. This pain has been 
described as cutting, gnawing, piercing, or burning. 

The pain of jjyloric ulcer is, as a rule, greater than that of 
cardiac ulcer. 

A very strong reason why this should be so is that the pylorus 
is relatively a fixed portion of the stomach, and in distention or 
contraction of the stomach it does not change its position according 
to the change in the position of the remainder of the stomach, con- 
sequently pull is made upon it, and it is this pull upon the already 
irritated structures that causes pain. This pain seems to occur 
most frequently in the mid-hours of the night. In some cases psy- 
chical disturbance, as anger or great emotion, seems to be conducive 
to its onset. 

(3) Tenderness. — In gastric ulcer, the tenderness which is 
in the epigastrium, in many cases to the right of the median 
line, may, because of adhesions, be localized in other parts of the 
abdomen. Ulcer of the stomach differs from gall-stone and all 
other colics, in that the patient is very sensitive in the upper 
abdomen, so that in many cases he will not bear even the slightest 
pressure, which is exactly the opposite to what occurs in colic, for 
here pressure seems to give relief. The tenderness to palpation 
and percussion associated with ulcer seems to vary according to 
the degree of distention of the organ — the greater the distention 
the more severe the associated pain. 

The tenderness elicited on palpation is of two types, super- 
ficial and deep. The superficial tenderness is merely an expres- 
sion of the hypersensibility of the skin, while the deep tenderness 
exjDresses the hypersensibility of the muscles, subserous perito- 
neum, and the peritoneum (parietal) in immediate association 
with the ulcer. When the tenderness is due to a hypersensibility 
of the rectus muscle, it will be found that the muscle is in a state of 
contraction, and that this contraction is localized to the upper 
segment. The contraction is more marked, generally, on the 
right side than on the left. This localized contraction, the so- 
called visceromotor reflex of Mackenzie, has, in some cases, been 
mistaken for a tumor. Sometimes, if the patient is very stout, it 





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is difficult with ordinary palpation to elicit pain in the rectus. It 
then becomes necessary to make very firm pressure, with the abdo- 
men as relaxed as possible, so that the area of tenderness may be 
defined. After having examined the abdomen it is well to examine 
the back. Here a tender area to the left of the tenth, eleventh, or 
twelfth dorsal vertebrae may be present. Percussion is frequently 
used to exactly define the area of tenderness. The lymphatics 
from the pylorus are in association with the upper abdominal 
wall on the right side, while the lymphatics from the cardiac end 
of the stomach are distributed to the upper abdominal wall on 
the left side. Since ulcer is most common at the pyloric end of 
the stomach, this will account for greater frequency of increased 
rigidity of the right rectus. 

(4) Diet. — Foods causing the production of pain, or increas- 
ing the pain already present, are those which are of an irritating 
nature or are difficult to digest. Of the first, are corn, crusts of 
bread, some breakfast foods, as grape-nuts, cherries which have 
been swallowed with their pits, etc. In the second class, pork, 
fresh baked bread and hot rolls, boiled cabbage, cucumbers, 
unripe fruits, strongly spiced foods, the various salads, and pota- 
toes may be included. Of the liquids causing an increase of ulcer 
pain, are those which are highly acid, or those which contain alco- 
hol, as whiskey and beer.. In many cases, also, those drinks 
which in themselves are stimulating or irritating, as coffee and 
tea, increase the pain. Cold drinks likewise sometimes induce a 
paroxysm of pain. The foods which are well borne in ulcer are 
meats, particularly scraped meat (beef), milk with lime water, 
and farinaceous gruels. Smoking sometimes seems to induce 
pain. Possibly this is a result of a stimulus to contraction known 
to be caused by nicotin. If the ulcer is situated near the pylorus, 
and the stomach is adherent to the pancreas, the pain is felt most 
severely in tjie intervals of gastric digestion. It is temporarily 
relieved by food or draughts of water. 

( 5 ) Change of Position. — If the pain is worse in certain posi- 
tions it can be assumed that the position in which it is worst is 
the one in which the stomach will be so situated that pressure 


will be made upon the ulcer bj tbe stomacb contents and abdomi- 
nal viscera. A change of position will also, in many cases, cause 
a kinking or bending of the pylorus, and this, in turn, produces 
traction upon the ulcer-bearing surface, thtis causing pain. 

It seems to be the rule that a right lateral position of the 
body is most painful in ulcer of the pylorus. The opposite seems 
to be true in cases of fundus ulcer. This rule, though, is true 
only before adhesions have formed. After their formation such a 
change of position of the body that the stomach will have a tend- 
ency to drop away from and pull upon the adhesive surface, would 
cause an excess of pain in the ulcer and adhesion area. In all cases 
the pains due to change in the position of the body are increased 
at the time of the spontaneous attacks common to ulcer. In many 
patients, in whom the ulcer is on the posterior surface, relief is 
found during the attack by lying on the abdomen. Lifting, strain- 
ing, carrying heavy loads, jumping, and rowing, and, in some cases, 
going up and down stairs, excessive respiratory movement, cough- 
ing and sneezing, running and walking may be provocative of pain. 
During attacks the patient may be crouched, the lower limbs being 
flexed, and the body bent forward. He may lie on the back or 
abdomen, or on either one or the other side, depending upon the 
location of the ulcer. 

(6) History. — Gastric ulcer generally gives a history of at- 
tacks of left-sided pain, which may or may not be accompanied 
by vomiting. This pain gi-adually passes off, and the patient may 
be free for several weeks or months; but again the pain comes 
on and lasts a little longer than in the first attack. Thus the 
pain continues to come and go, each attack being of briefer dura- 
tion than the previous one, and occurring at successively shorter 

Conditions accompanying and associated with gastric ulcer 
are: (1) Vomiting, which comes on generally after the ingestion 
of food, especially if the food be of an irritating kind. It occurs 
one-half to two hours after eating, but may take place almost 
immediately. The vomitus of an ulcer patient is somewhat char- 
acteristic, in that it often contains pure blood. 


(2) Constipation is frequently present. 

(3) Anemia sometimes occurs, and is due to the loss of blood 
in the vomitus or in the stools. 

(4) Blood is sometimes seen in the stools after a meat-free 

(5) Enteroptosis frequently accompanies pyloric ulcer. In 
this case a properly adjusted abdominal supporter, the taking on of 
fat, or the presence of pregnancy frequently eases the condition, 
the cause of the relief in the latter instance being due, as Schmidt 
suggests, to the elevation of the abdominal viscera by the rising of 
the enlarged uterus. 

(6) Pyrosis or regurgitation of sour-tasting fluids sometimes 

(7) Belching of gas and tympanitis are common. The belch- 
ing of gas, with the accompanying sour-tasting eructations, is 
almost pathognomonic of gastric ulcer. 

Peeforatixg Ulcers. — The perforation of a gastric ulcer is 
one of the tragedies of medicine. It is ushered in with pain 
(Eisendrath, 579), which is severe and sudden, and of an intense, 
agonizing, or stabbing character. If the ulcer is on the anterior 
stomach wall, and is in intimate contact with the anterior abdom- 
inal wall, the pain may be felt at first around the navel. In either 
case, as the associated peritonitis extends down into the right 
iliac fossa, it rapidly becomes diffused. The original pain is now 
accompanied by the sharp, intense pain that is so characteristic 
of a spreading peritonitis. The abdominal muscles become rigid, 
and marked tenderness develops on the right side. A complica- 
tion of this kind can be diagnosed from appendicitis in that the 
muscular rigidity in appendicitis is more markedly localized to 
the right iliac fossa, and also from the fact that in gastric ulcer 
there is often a history of hematemesis, pain after eating, and 
occult blood in the stools. If the case is first seen several hours 
after perforation, it is almost impossible, because of the asso- 
ciated peritonitis, to diagnose the origin of the pain. 

Diagnosis of Gastric Ulcer. — The pain of gastric ulcer dif- 
fers from that of gall-stone colic in the following ways : 


(1) Pain in gall-stone colic is paroxysmal, and has a tendency 
to radiate over the right side to the right scapula; also it is felt 
in the right shoulder. 

(2) Vomiting nearly always relieves the pain of ulcer, while 
it may have no noticeable effect on gall-stone colic. In ulcer the 
vomitus often contains blood. In gall-stone colic none is present. 

(3) Local anesthetics and mild drinks often ease the pain of 
ulcer. They would have no effect on gall-bladder colic. 

(4) In gall-stone colic there is frequently a history of pre- 
vious attacks, with an accompanying jaundice. 

Cholecystitic pain is also often mistaken for ulcer pain; but 
in the former the pain is constant, and the enlarged and very ten- 
der gall-bladder can be felt. Pain of hepatitis has sometimes been 
confused with the pain of gastric ulcer, but in the former there 
is a tenderness beneath the right costal margin, and the liver is 
generally enlarged. 

From epigastric hernia gastric ulcer can be diagnosed by the 
physical signs of the hernia which are present, and the impulse 
on coughing and straining. Duodenal ulcer is hard to distinguish, 
as the pain symptoms in the two conditions are almost identical, 
but alypin and cocain often relieve the pain of gastric ulcer, 
while they have no effect on that due to ulcer of the duodenum. 
To distinguish pyloric from duodenal ulcer Mennier (66b) has 
devised the following test. He gives the patient one pint of 

In Pyloric Ulcer. In Duodenal Ulcer 

The pain is relieved after a The pain remains with the same 
few swallows, and gradually intensity for 5, 10, or 15 

disappears. minutes ; then the patient 

belches gas, and suddenly the 
pain is relieved. This re- 
lief is synchronous with the 
opening of the pylorus, the 
belching of gas, and the pas- 
sage of the stomach contents 
into the duodenum. 


Acute pancreatitis often gives rise to symptoms similar to 
those of gastric nicer; bnt here there are generally an associated 
shock and collapse. The pulse is considerably elevated, and a 
tumor (enlarged pancreas) often develops and lies across the 
upper abdomen. 

Angina pectoris has also been mistaken for ulcer-pain; but 
the associated collapse and fear of impending death, the presence 
of unconsciousness, and the radiation of the pain to the left 
shoulder and down the left arm make the diagnosis easy. In 
angina pectoris vomiting does not occur, and diet, as a rule, has 
no effect on the incidence of the pain; but exercise and violent 
emotion seem to be inciting factors. 

Appendicitis pain, especially if it occurs in the region of the 
umbilicus and is associated with vomiting, has frequently been 
mistaken for that due to gastric lesions. In appendicitis Morris's 
and McBurney's points may be tender, and there may also be re- 
flected visceral hyperalgesia in the area usually associated with the 
appendix. These, with the absence of definite symptoms of stom- 
ach involvement, make the diagnosis certain. 

Renal colic can hardly be mistaken for gastric-ulcer pain; 
the peculiar radiation of its pain downward and inward to the 
pubes makes its differentiation somewhat easy. 

The pain of gastric carcinoma will be differentiated when it 
is considered a few pages further on. 

The diagnosis of chronic ulcer of the stomach is easy, and 
when all of the classical symptoms are present can scarcely occa- 
sion perplexity. When, however, this is not the case, it may be 
exceedingly difficult, or even impossible, to make a positive diag- 
nosis. Im23ortant diagnostic factors have already been indicated. 
Two other diseases of the stomach, gastralgia, or gastrodynia (as 
the exjDression of functional nervous disturbance), and carcinoma 
resemble the symptom-picture of ulcer when ulcer deviates from 
its typical course. It seems advisable to tabulate their important 
points of difference, as follows : ^ 

' Modified from ' ' Modern Clinical Medicine, ' ' Diseases of the Digestive 
System, page 188, 




Tongue varies, is often pale, 
and fissured at the borders 
or upon the surface. 

Frequent eructation of odor- 
less gas. 

Taste unaltered, dr3Tiess of 
mouth frequent; sometimes 

Appetite irregular, capricious. 
Eating brings rehef. 

Varying sensations in the 
stomach, sometimes heat, 
sometimes cold. 

Spasmodic, burning pain, in 
dependent of food, often 
ameliorated by the latter or 
by pressure upon the stom- 
ach. Pressure frequently 
eases the pain, though it is 
common for the anterior ab- 
dominal wall to be hyper- 

Tongue, dry, red, with 
white streaks in the 
center, or is smooth 
and moist, or slightly 

Eructations either rare, 
or acid with pyrosis. 

Taste unaltered. 

Appetite good in the in 
tervals; thirst, eating 
causes pain. 

Burning sensation in 
the stomach. Circum- 
scribed boring pain, 
often radiating pos 

Pains, gnawing, rare 
upon an empty stom- 
ach, usually appearing 
after eating or upon 
motion and on assum- 
ing positions which af 
feet the stomach; in- 
creased upon pressure 
Pressure points (hyper- 
algesic) upon back 
Pressure over abdo- 
men increases the pain. 
Sometimes at the time 
of paroxysms it will 
relieve the pain. Pa- 
tients sometimes pre- 
sent the chlorotic type. 

Tongue, pale; in rare 
cases, very red, dry. 

Frequent fetid eructa- 

Pappy, insipid taste. 

Appetite decreased or 
anorexia; early repug- 
nance to meat; eating 
causes pain. 

Sensation of weight in 
stomach ; drawing 
pains of varying char- 
acter, perhaps pain in 
the shoulder. 

Continuous sensations 
of dull pain, period- 
ically increasing t o 
paroxysms, often pro- 
duced by pressure or 
increased by it. 

Often conjoined with hyster- 
ical symptoms. Occurs at 
aU ages, more frequently in 
women than in men. 

Most frequent in middle 
life; rare in children 
Accompanied by £ 
varying psychical con- 
dition, frequently great 

Most frequent between 
the 40th and 60th 
years. Psychical con- 
dition that of depres- 
sion; melancholia, but, 
strange to say, less 
profound than in se- 
vere cases of ulcer. 




No tumor on palpation, un- 
less, as rare exceptions, when 
foreign bodies (hair, etc.) 
have been swallowed. Chem- 
ism varies; absence of lactic 

No symptom of perforation. 

Most frequent about the time 
of the menopause. 

History of nervous disorders, 
as neurasthenia, hysteria, 
neuralgia, etc. 

No pain between attacks. 

Distention of stomach pro- 
duces no pain. 

When the ulcer is situ- 
ated at the pylorus 
with consecutive hy- 
pertrophy, an ovoid, 
smooth tumor at the 
right of the median 
line may be palpated; 
occasionally, in old ul- 
cers with a hard base 
and callous borders, a 
palpable circumscribed 
tumor may be felt. 
Perforation of the 
ulcer and consequent 
adhesions with the 
head of the pancreas, 
the left lobe of the 
liver, the spleen or 
the omentum, causes 
a tumor which does 
not move with the 
respiratory excursion 
HCl present and usu- 
ally increased. 

Perforation into neigh- 
boring organs with 
characteristic symp- 
toms may occur fre- 
quently after apparent 
brief duration of the 
disease, even occurring 
without prodromes. 

Most frequent at from 
15 to 35 years. 

History of anemia, vom- 
iting of blood, dyspep- 
sia, tuberculosis, etc 

Pain attacks may be 
absent for years, only 
to become again mani 

Distention produces 
most severe pain, but 
it is a very dangerous 


Tumor of varying size 
and shape, nodular or 
smooth, distinctly pal- 
pable; as a rule, pas- 
sively movable, occas- 
ionally also showing 
active excursions dur- 
ing respiration. In the 
majority of cases ab- 
sence of HCl ; absence 
of peptic digestion; lac- 
t i c acid, lab-ferment 
sometimes absent (can- 
cer of the pylorus), 
sometimes present 
(cancer of the fundus). 
Secondary glandular 
enlargement ; m e t a s- 

Perforation ; implica- 
tions of neighboring 
organs only after pro- 
longed existence of the 

Most frequent late in 

History of cancer in fam- 
ily, also of a gradually 
progressive weakness. 

Attack, when it comes 
on, generally lasts till 
cancer is removed or 
till death occurs. 

Distention is painful. 




Very little effect on general 

General health greatly 

General health greatly 

The chemism of digestion not Digestion of starches fre-^ Digestion insufficient; 

especially altered. 

quently slow; that of 
meat normal, or even 
accelerated ; usually 
hyper chlorhydria. I 

usually absence of free 
HCl; and the forma- 
tion of organic prod- 
ucts of decomposition. 

Epigastric pulsation. Regu-' Alkalies and albumin 

lation of diet has no effect, 

Vomiting irregular, vomitus 
sometimes contains only 
mucus, sometimes more or 
less digested stomach con- 
tents, rarely mixed with bile. 

No hematemesLs, except as 
accompaniment of very rare 

Alm ost invariably stubborn 
ccmstipation; normal evacu- 
ations very rare; occasion- 
ally fluid mucoid dejecta, the 
so-called pseudo - diarrhea . 
Mucous colic, that is, colitis 
mucosa membranacea. 

ease the pain. 

Epigastric pulsation 
present with marked 
emaciation. Regula- 
tion of diet has no 

Vomiting as a rule, im- 
mediately or shortly I 
after eating, and fre-j 
quently the first symp-i 
torn of the disease;; 
it occurs very rarely 
without the taking of, 
food, vomitus hjT^er- 

Vomiting of Hght red 
blood or coffee-ground 
masses ; usually re- 
peated in a brief space 
of time, occasionally 
very profuse, followed 
by extreme anemia and 
collapse; compensation 
with comparative rap- 
idity; blood in the 
feces; occult hemor- 

Severe and frequent 
vomiting, often period- 
ic; occasionally, also, 
before the ingestion of 
food; vomitus is mu- 
coid if acidity due to 
the presence of organic 
acids is present; vom- 
itus shows but shght 
progress of digestion; 
sometimes cancer cells 
are present. Also in 
some- cases the Boas- 
Oppler bacillus. 

Decomposed blood more 
frequent than fresh; 
quantity usually small, 
but, vomiting having 
once appeared, it re- 
curs frequently at 
short intervals. 

Bowel discharges vary; Almost invariably bow- 

not infrequently diar- 
rheal in consequence of 
intestinal irritation ; 
lientery if perforation 
of the ulcer occurs into 
the colon. 

els stubbornly consti- 
pated; lientery after 
perforation of the ulcer 
into the colon. 






No fever. 

Mild fever with adhe- 

Fever rare, and only 

sive inflammation after 

towards the termina- 

rupture of the ulcer, 

tion of life; initial fever 

or following profuse 

quite rare. 


Skin pale, rarely ruddy. Skin 

Skin usually ruddy, ap- 

Skin sallow, yellow- 

of normal turgescence. 

pearance good, anemic 

ish, dry, and flaccid; 

only after profuse hem- 

marked cachexia. 

orrhages; frequently 

the pallor is visible 

in the mucous mem- 

branes, and even in 

the cheeks. 

New Growths of the Stomach. — 'New growths of the stomach 
cause pain, especially when they encroach upon the pylorus and 
thus produce a partial obstruction with a consequent gastric dila- 
tation. Carcinoma causes pain, particularly when it ulcerates, 
and when infection takes place, which gives rise to lymphangitis. 
According to Eisendrath, there is, in gastric carcinoma, at first 
only a heaviness after eating, then later a pain of a dull, gnawing 
character referred to the epigastrium. There is also a marked 
local tenderness. In carcinoma, or other new growths of the 
stomach, generally there are in some stage of their development 
characteristic areas of cutaneous hyperalgesia. The figure on the 
next page illustrates the areas mostly involved. 

One of the earliest symptoms of carcinoma is the feeling of 
pressure in the epigastrium, occurring a short time after eating. 
There may also be sensations of burning, fulness, or of epigastric 
tension. When the pylorus becomes stenosed the pains assume a 
boring or twisting character, and are due to the spasmodic con- 
traction of the stomach, which is attempting to force its contents 
through the narrowed opening. When the cancer is at the fundus 
pain is present, moi^e especially when the stomach is full, and 
may radiate towards the breast and back. In some cases it is 
started by the ingestion of food, while in others it is produced by 
mechanical shock or by change of position. 



The pain in gastric carcinoma may vary in location, depend- 
ing a great deal upon the site of the new growth. It seems as 
though the nearer the growth is to the pyloric end of the stomach, 
the farther to the right and the closer to the nmbilicus will be the 
pain. Sometimes this pain radiates around the sides to the back, 

Fig. 97. — Hyperalgesic Zones in Cancer at Cardiac End of Stomach. 

and rests between the shoulders, or runs anteriorly uj) under the 
lower part of the sternum; or it may radiate backward into 
the iliac regions. The reason for this is not clear. The appear- 
ance of pain on the back seems to be favored by constipation 
(Schmidt) ; it is relieved by purgation. Pain is also frequently 
present in the supraclavicular region on the left side. 

The pain in gastric carcinoma is gTeatly increased when in- 
fection takes place, and a perigastric peritonitis results. The 
local tenderness is also much increased, and extends over a wider 
area. Creaking sounds, due to the movement of the inflamed peri- 
toneal surfaces over each other, may be heard on auscultation, or 
be felt on palpation. The pain is constant ; and is increased on 
the taking of food. Carcinoma, although having a resemblance 
to gastric ulcer, should be distinguished in diagnosis. In gastric 
ulcer pain comes on immediately after the ingestion of food ; no 
tumor mass is found ; a localized area of extreme tenderness is 
present in the epigastrium; and the stomach contents yield an 


excess of hydrochloric acid with the absence of sarcinse and lactic 
acid. The exact opposite of these conditions prevails in gastric 
carcinoma. In gastric ulcer the pain generally occurs in attacks 
at irregular intervals, and frequently a coffee-ground vomitus is 
present, while in carcinoma the pain is more continuous, and coffee- 
ground vomit is, as a* rule, absent. In gastric ulcer the ingestion 
of food increases the pain, while in gastric carcinoma this is less 
liable to occur. In some cases of carcinoma, in which ulceration 
has occurred, the pain has a character similar to that of gastric 

The posture of the patient generally plays but a minor role 
in the production of pain in gastric carcinoma, though the pain 
is worse in that position in which there is an excess of pressure 
ui^on the carcinomatous mass, or in which an abnormal degree of 
traction is exerted upon the surrounding tissues. Generally, since 
the carcinoma is most frequent at the pyloric end of the stomach, 
lying upon the right side is more painful than lying on the left. 
In case adhesions have formed, change from one position to an- 
other may be very painful. Rapid changes of position are gen- 
erally productive of pain, because of the sudden movement of 
the tumor mass from one place to another. 

It is claimed that benign stenosis of the pylorus is much more 
painful than is carcinomatous stenosis, because in carcinomatous 
stenosis the patients early lose their appetite, and there is no 
great mass of irritating food clamoring for passage, as in a be- 
nign pyloric stenosis. Also, owing to carcinomatous invasion and 
lack of nutrition, the musculature of the stomach in carcinoma 
soon becomes weakened, and is unable to exert as great a propul- 
sive force upon the contained food mass as in pyloric stenosis. 
These conditions are present only late in carcinoma ; early in the 
disease, the diet being the same as in benig-n stenosis, the pains of 
carcinoma may closely resemble those of the latter. Sometimes in 
carcinomatous pyloric stenosis the colicky pains may come on sev- 
eral hours after eating. They are common about one or two o'clock 
in the morning. In this respect carcinoma resembles gastric ulcer. 

The pain in gastric carcinoma is due to: 


(1) The Local Disease. — In gastric carcinoma, although hy- 
drochloric acid is not present, other organic acids, such as lactic 
acid, etc., are formed, and these give rise to excessive peristalsis. 
When the growth is at the pylorus, evacuation of the stomach is 
hindered, and pain results from tension of that part of the 
stomach M^hich lies between the pylorus and the advancing peris- 
taltic wave. Should ulceration occur, the fine nerve endings are 
exposed in the bed of the ulcer, and are irritated by the excessive 
amount of organic acids which are present in the stomach. This 
irritation reflexly causes an increased peristalsis and very severe, 
pain. In the latter case the modus operandi of pain production 
is exactly as in ulcer. Mansell Moullin, while he recognizes the 
increase in peristalsis, however thinks that the pain of carcinoma 
is due to a hyperemia of the peritoneum, which causes it to become 
more sensitive and to react to peristaltic traction by pain produc- 

(2) Lymphangitis. — This is very frequent in gastric car- 
cinoma, and, according to Lennander and others, is the cause of 
the pain felt in this condition. They hold that the inflammation 
progresses into the mesogastrium until it reaches an area where 
cerebrospinal nerves are encountered and are irritated, and pain 
is produced. Naturally, when the inflammation is extending 
backward along the lymph paths, the lymph glands would be in- 
volved and become larger. Pressure may then be exerted upon 
adjacent nerves and give rise to pain. Thus, the pain, radiating 
around the chest wall, may be caused by pressure on the intercos- 
tal nerves from the enlarged glands of the prevertebral area. 

(3) Metastases. — Metastatic growths undoubtedly cause many 
of the radiating pains of gastric carcinoma. Metastasis may 
either precede or follow the inflammatory swelling of the pre- 
vertebral lymph glands, and alone, or in association with it, give 
rise to the radiating chest and abdominal pains. The left shoul- 
der pain, so often complained of by the patient with gastric car- 
cinoma, may be due to pressure on the acromial nerve by the 
enlarged lymph gland or glands in the supraclavicular region. 

Diagnostic symptoms associated with cancer of the stomach 


are: in the early stages a simple regurgitation of sour fluids; 
in later stages the regurgitation is changed to a vomit, and the 
fluid is of greater quantity, often fermented, and sometimes con- 
tains blood and the Boas-Oppler bacillus. If the cancer is well 
advanced, a definite tumor frequently can be located in the epi- 
gastrium. This tumor moves with respiration, and is tender to 
the touch. In malignant disease of the pylorus bile may be present 
in the vomitus. This may be accounted for by the lack of tone in 
the pyloric sphincter, due to the atonic condition of the muscula- 
ture. The ingestion of food almost immediately starts the pain, 
which generally persists until the stomach is relieved of its con- 
tents by vomiting or by exit through the pylorus. The kind of diet 
influences the severity of the pain. Indigestible substances or those 
hard to digest, as cabbage, corn, pork, tough meat, and rye bread, 
generally are productive of great pain. Left-sided pleurisy is 
often associated with gastric carcinoma, and frequently gives rise 
to chest pains. 

Pains due to metastases in other organs may follow upon 
a train of symptoms indicative of gastric carcinoma ; these pains 
are most frequently located in the epigastrium, and are not in- 
fluenced by the ingestion of food. 

Schmidt claims that in many cases of tuberculosis with 
dyspepsia the symptoms could be confused with those of gastric 
carcinoma, because of the loss of weight, anorexia, and epigastric 
pain due to coughing. 

Perigastric Adhesions. — In case of long-continued inflamma- 
tion and lymphangitis of the stomach, such as result from gas- 
tritis or from ulcer, the pain which is present is, in almost all 
cases, due to the adhesions which join the stomach to the adjacent 
viscera. Adhesions existing between the anterior gastric wall, or 
pylorus, and the parietal peritoneum are the most painful. A 
factor of importance in the diagnosis of gastric-adhesion pain is 
that the pain is made worse by change of position, though in the 
change of position the location of the pain remains the same. 
Another factor is that it is worse during active peristalsis or dis- 
tention of the stomach, and is always located in the same area. 


Palpation of the abdominal wall and stomacli, as a means of 
localizing' the lesions, is useful, for if adhesions are present pres- 
sure made in an upward direction from the lower border of the 
stomach will increase the pain. If the adhesions are to the Tight 
or are on the anterior border, pressure made over the epigastrium 

- Area of pain in gastric ulcer 

Area of pain in present case 

Outline of stomach 

Fig. 98. — Point of Tendeeness and the Area of Pain in a Case of 
Perigastric Adhesions. 

will cause pain to shoot out from the right over the border of the 
stomach. If the adhesions are on the posterior gastric wall pres- 
sure over the first and second lumbar vertebrse will often cause 
pain. When the adhesions are between the anterior abdominal 
wall and the stomach thej are very apt to be confused with gastric 
ulcer (Cumston, 580). Erdman (581) claims that in gastric 
adhesions no pain is complained of on any movement of the 
stomach, only a sense of soreness being present. This is contrary 
to the opinion of the majority of observers. 

W. Langdon Brown (583) describes a pain situated just be- 
low the costal arch and a little to the left of the middle line. 
Its onset had no relationship to the ingestion of food, but came 
on as soon as the direct posture was assumed. On operation a 
firm adhesion to the anterior abdominal wall, about the size of a 
half crown, was found midway between the gi-eater and lesser 
curvatures, and rather nearer the cardiac than the pyloric orifice. 


The stomach, was in direct contact with the anterior abdominal 
wall. In some cases adhesions between the anterior abdominal 
wall and the anterior wall of the stomach may cause such severe 
symptoms that the patient is unable to assume the upright posi- 
tion and remains bent forward (Gilbride, 582). 

The following points, as given by Brown, are indicative of 
perigastric adhesions : 

(1) The symptoms have not infrequently been preceded by 
those which are more characteristic of gastric ulcer or of gall-stone 
colic; (2) local tenderness is very frequent; (3) pain is greatly 
influenced by the position of the patient ; (4) vomiting, as a rule, 
is not present; (5) careful dieting does not seem to have much 
influence on the pain. Pressure over the last two dorsal verte- 
brae and the first and second lumbar frequently causes pain in 
adhesions of the posterior gastric wall. 



After a consideration of the direct pains of gastric origin it 
is necessary to consider those referred and reflected pains that are 
so often confused with them. These pains are of nervous origin 
and are due to neuralgia of the sympathetic or of the intercostals ; 
or are projected pains from cord lesions, or are referred or reflected 
pains from lesions in organs at a distance. 

ISTeuralgia of the sympathetic or of the vagus, which supply 
the stomach, may occur just the same as does neuralgia of other 
nerves in other parts of the body. In neuralgia of the vagus 
nerve the pain is felt in the area of distribution of the sensory 
fibers of the affected nerve, or is reflected through communicating 
branches into the distribution area of the sensory part of related 
nerves. In involvement of the sympathetic, pain is not felt in the 
area of distribution of the sympathetic fibers, but the irritation 
is referred to the cord and thence' outward into the distribution 
area of those spinal nerves whose cord-associated neurons have 
been stimulated. 


This neuralgic condition may exist in either one of the gastric 
nerves, namely, the vagi and the splanchnics. Both may be sub- 
ject to disorders causing pain. Schmidt reports a case of vagus 
neuralgia in which pressure in the left external auditory meatus, 
or irritation over the painful area with a combination of oil of 
mustard, menthol, and liquid petrolatum, caused the pain to cease. 

The pain of intercostal neuralgia is often confused with that 
arising from the stomach, but, though the pain may be present in 
the epigastrium, the diagnosis is easy if it is remembered that in 
intercostal neuralgia there are tender points in the corresponding, 
intercostal spaces, one or two inches from the spine. These are 
absent in gastralgia. The pain of intercostal neuralgia is also in- 
creased on exposure to cold and to draughts. 

Lesions of the cord are often mistaken for gastric disorders 
because of the projected pain which they occasion; but here there 
is an absence of gastric symptoms ; the pain is generally bilateral, 
and there are other well-defined symptoms of the nervous dis- 
order. It is claimed by Schmidt that gastric crises (tabes) often 
have a tendency to a left-sided localization. (Schmidt, 584, p. 

It is also characteristic of tabes that at the time of the epi- 
gastric pains, or crises, there is almost always an uninterrupted 
and exceedingly painful vomiting. The vomit consists at first of 
food, later of a mucous fluid which is sometimes mixed with bile 
or tinged with blood. This is accompanied by marked nausea and 
vertigo, as well as by cardialgic pains, which at times reach a 
terrible degree of intensity. These attacks may appear at the 
very beginning of the disease. 

Referred pains to the epigastrium are often due to the ap- 
pendix, uterus, ovaries, gall-bladder, in some cases, to aortic 
aneurysm, the pancreas, spleen, even umbilical hernia, and Addi- 
son's disease. 




The value of pain in the diagnosis of intestinal lesions is of 
more moment than is apparent from a cursory view of the sub- 
ject. In a patient in whose case the diagnosis is obscure the cor- 
rect interpretation of the pain manifestation is of vast importance, 
and may be the means of eliciting the cause of otherwise inex- 
plicable symptoms, and lead to effective treatment. 

For convenience the intestine is divided into two portions, 
namely, the large and small, both of which are united to the body 
wall by a mesentery. The mesentery attached to the large bowel 
is not as long nor as mobile as that attached to the short one, so 
that when the large intestine is distended beyond its normal limit 
it gives rise to more pain than does a proportionate increase in 
distention of the small intestine. 

Etiology of Pain — The researches of Mackenzie, Lennander, 
and well-known anatomists, physiologists, and surgeons have 
shown that the intestinal mucosa, of itself, is insensitive to or- 
dinary forms of tactile sensibility; that it can be pinched, 
punched, and resected without producing pain, provided no trac- 
tion is made upon the mesentery and that no tension is exerted 
on the muscular walls. There are, therefore, two distinct types 
of intestinal pain — possibly more. The one due to the pull and 
drag upon the adjacent peritoneal structures; the other a true 
intestinal pain due to tension within the muscular structures. 
This latter type of pain — deep sensibility pain — has often been 
misinterpreted. As has been stated, the adequate stimuli for 



visceral pain are not those of the ordinary tactile or thermal types 
so well known for the skin and mncoiis surfaces. The adequate 
stimulus here is tension and when the threshold of deep pressure 
sensibility is reached pain results. It must be recalled that while 
tactile, thermal, chemical, and possibly other forms of stimuli 
may not be capable of exciting specific receptors in the intestinal 
canal, nevertheless they are capable of inducing motor reflex ac- 
tivities causing contraction, and that contractions which cause 
tension to mount to the deep sensibility threshold result in pain. 
Deep sensibility sensations may be transmitted by the sympathetic 

However, many do not believe that pain as a sensory entity 
exists in the intestine. Since these hold that pain is not present 
in the intestines, they must be asked how and in what manner it 
is produced, since it undoubtedly is felt in lesions of the intestinal 
viscera. It was formerly held that pain, as pain sensation, is 
not transmitted by sympathetic fibers; therefore, the only nerve 
fibers that could transmit pain directly were the fibers of the cere- 
brospinal system, which, except the vagus (Bayliss and Starling), 
are not in any way associated directly with the intestinal viscera, 
although, in some cases, they are indirectly associated through the 
phrenic, the lower six intercostals, the lumbar, the sacral nerves, 
and the splanchnics (Lennander). The sympathetic cannot carry 
stimuli which may be directly interpreted as painful, but do carry 
stimuli which are reflected to the body wall and are there felt as 
pain. According to Lennander, "all painful sensations within the 
abdominal cavity are transmitted only by means of the parietal 
peritoneum and its subserous layer, both of which are richly sup- 
plied with cerebrospinal nerves around the whole of the abdominal 
cavity, possibly with the exception of the small area in front of 
the vertebral column, lying below the crura of the diaphragm and 
between the two chains of sympathetic nerves." Here, he says, as 
far as he is aware, no cerebrospinal nerves have as yet been demon- 
strated. On a few occasions he has observed that within this area 
the patient does not respond to hard pressure with finger or instru- 
ment, nor, furthermore, does he experience any sensation when 


a small portion of the mesenteric attachment at this point is put 
on the stretch. This coincides somewhat closely with the views 
of Mackenzie, that it is only the siib-serons j)eritoneal layer which 
is the cause of pain in intraabdominal lesions. However, these 
elaborate hypotheses devised by Mackenzie and Lennander, to show 
why pain was felt in intestinal disorders when they were insensi- 
tive to tactile sensibility, have all been swept away by the recogni- 
tion of the fact that the adequate stimulus for intestinal pain pro- 
duction is tension and not the well-known pain-producing stimuli, 
touch, heat, pressure, etc., of the skin and the mucous membranes ; 
that the intestinal pain belongs to the type of deep sensibility pain 
and that it is conveyed through the sympathetic nerve fibers. It 
had been held for a long time that the sympathetic nervous system 
carried no pain fibers. Langley and Head hold the contrary 
view. In any case, these sensations are conveyed to the cord, 
where they stimulate certain cord segments, and thus cause pain to 
be referred to the somatic distribution area of these segments or 
zones. -^ 

That pulling and stretching of the mesentery can cause pain 
is shown by Lennander, who, in describing an operation, says that 
"pain was occasioned by the placing or removal of gauze com- 
presses between the viscera and the parietal peritoneum, by the 
dragging forward of the cecum, of the appendix vermiformis, 
or of any other organ whose normal attachment to the anterior 
abdominal wall was put on the stretch." The same principle 
applies to the stretching of abdominal adhesions, which may con- 
nect the viscera with the anterior abdominal wall. On the other 
hand, should a compress lie between the viscera without coming 
into contact with the anterior abdominal wall the patient experi- 

^ Wilms (33b) believes that only the spinal nerves can convey pain sen- 
sation. He says that the intestine of man has no sensory nerves, but that in 
the mesentery the sensory nerves run almost to the intestines. The pain in 
intestinal colic is caused by a pull on these nerve terminals and, therefore, 
the pain is referred to the area where the mesentery is attached to the ver- 
tebra — rather that the pain is referred put along the peripheral distribution 
of the spinal nerves connected with the same segment of the cord as are the 
nerves from the mesentery, so that, when irritation occurs in their distribution 
area, the sensation (pain) is referred along the body wall. 




























1— 1 

h- 1 






1— I 









ences no sensation when it is removed. Similarly no pain at- 
tends the stretching or breaking up of adhesions which have no 
connection with the abdominal parietes. The parietal perito- 
neum along the thoracic aperture and around the foramen of 
Winslow is especially sensitive to stretching and displacement. 
Robinson (265) reports the absence of cutaneous hyperalgesia in 
cases of acute intestinal obstruction. 

Pain due to stomach 

Pain due to small intes- 

Pain, enterocolonic 

Pain due to large intes- 

Pain due to rectum and 

FiG.lOl. — Points to Which Pain Is Refekred in Lesions of Different 
Parts op Intestinal Tract. 

The pain of intestinal origin is very imperfectly localized. 
The reflex hyperesthesial and abdominal projections are better 
capable of exact localization. They are therefore of great prac- 
tical value. 

If the lesions are of the small- intestine the pain is reflected to 
the anterior abdominal wall in the interval between the umbilicus 
and the ensiform; if the disturbance is in the large intestine the 


pain is felt slightly below the umbilicus. In lesions of the rec- 
tum and sigmoid it is felt directly above the pubes. The drawing 
on the previous page, according to Mackenzie, shows his deductions. 

A peculiarity of referred somatic pain is that it seldom is felt 
in the posterior distribution of the dorsal segments, but is almost 
invariably present in the anterior distribution area. "When re- 
flected somatic pain is present in the posterior distribution, it is 
always present at the same time in the anterior, though the an- 
terior distribution may be present without the posterior involve- 

Wilson (896) advances a hypothesis which, because of its 
novelty, is quoted here. He says: "Muscle fiber has two oppos- 
ing types of activity: (1) the contractile activity, due to contrac- 
tion of the longitudinal elements of the fibers; and (2) the ex- 
pansile activity, due to contraction of the transverse elements of 
the fibers, thus causing them to lengthen. Some pathological ele- 
ments cause the bowel to expand instead of contract, so that there 
is an active expansion." He thinks that the rigid arch of the 
abdomen in peritonitis is due to the expansile activity of the 
muscle fibers in the gTit, for he cannot understand how a contrac- 
tion of the abdominal muscles will produce an arched instead of 
a straight line. He also claims that in some cases in which the 
irritation causes a stimulation of the expansile activity a conflict 
takes place between the two tendencies, resulting in pain, the so- 
called colic. 

Pain may also be referred to the peripheral distribution of 
the genitocrural, the ilioinguinal, the iliohypogastric, the exter- 
nal cutaneous, and the accessory nerve to the external cutaneous. 
In these cases the pain is due to ]3ressure made upon these nerves 
by increase in size of the cecum or of the sigmoid. It is very fre- 
quent in new growths of these organs. 

Besides the above causes of pain, due to intestinal lesions, we 
have two others which are generally forgotten, or, if not forgotten, 
are thought to be of such slight importance that they are not 
mentioned. These are the pain due to pressure upon adjacent 
nerves by lymphatic gland enlargement, such as is found in tuber- 


culous intestinal lesions and leukemia, and, second, the pain due 
to irritation of the large ganglia of the sympathetic. The latter, 
either by direct involvement in the inflammatory process or by 
irritation from stimuli received through peripheral branches, 
become supersensitive and react abnormally to normal stimuli. 

By many observers the origin of the epigastric pain which 
is felt in so many intraabdominal lesions is supposed to be due 
to an irritation of the solar plexus. This is undoubtedly errone- 
ous, for it seems that the solar plexus has a direct connection 
"with pain production, only in so far as it acts as a clearing house 
for stimuli received through the different abdominal sympathetic 
ganglia. From the solar plexus are derived the sympathetic 
fibers which connect with the sixth to the ninth visceral segments 
of the cord. Irritation to these fibers, arising either independ- 
ently in the fibers or transmitted from the ganglia, is carried to 
the cord, whence it is referred to the body wall as pain. The 
maximum point of tenderness of the seventh dorsal segment is in 
the epigastrium. Since it is generally in the area of maximum 
tenderness that subjective pain is felt, it is in this area that pain 
associated with most of the abdominal lesions is perceived. 

Should intestinal disease be suspected as a cause of abdominal 
pain there are certain characteristics of the pain-symptoms that 
lead to a fairly definite decision, not only as to the involvement of 
the intestine, but even to the segment of the bowel which is in- 
volved. The characteristics aiding in the diagnosis are the loca- 
tion of the pain, its type, manner of onset, variation (depending 
upon the position of patient), duration, result, and history of the 
pain, and the associated symptoms. 

Location of the Pain. — iSTearly all painful lesions of the in- 
testine first betoken their presence by circum-umbilical pain. In 
appendicitis this is very common, but, as the pathology progresses, 
the site of the pain is changed from the umbilical region to the 
right' lower quadrant of the abdomen. In diseases of the large 
intestine the pain is generally felt below the umbilicus, while in 
those of the small intestine the pain is generally located above. A 
peculiar characteristic, and one that is of great value in diagnosis, 


is that in diseases of the large bowel pressure on the abdomen, over 
the site of the colon (which, in its transverse division, is above the 
umbilicus, and in its ascending and descending divisions to either 
side of it), will produce pain in the mid-abdominal zone without, 
in many cases, producing any pain at the point of pressure. In 
lesions of the small intestine the contrary holds true, for pressure 
in the area below the umbilicus generally causes j^ain in the supra- 
umbilical zone. If the pain that is felt closely resembles that pro- 
duced by stomach disorders, as is so often the case in duodenal 
ulcer, and an examination of the stomach fails to reveal any abnor- 
mality, the duodenum should then be suspected as the cause of the 
pain. It is very common for the duodenum, because of its close 
nervous relationship with the stomach, to produce symptoms sim- 
ilar to those of gastric disturbances. In some cases the pain of 
intestinal disease is felt in the back, in one or the other lumbar 
region. Pain in the back generally alternates with the pain of the 
anterior abdominal wall. As a rule both are not coincident. 

Visceral pain depends for its localization largely upon the 
fixity or the mobility of the organ affected. The more fixed the 
viscera, as a rule, the more constant the pain. Thus in the mobile 
and freely moving small intestine the localization is diffuse, and 
centralizes chiefly about the umbilicus. In the movable parts of 
the colon pain is felt between the umbilicus and the pubes. In 
diseases of the duodenum, the last few inches of the ileum and the 
ascending and descending colon, and in lesions at the hepatic, 
splenic, and pelvirectal flexures the pain is felt at the points where 
these structures are joined to the abdominal wall. 

Type of the Pain A sudden abdominal pain, associated with 

vomiting, should always suggest an acute abdominal lesion, such 
as an obstruction by volvulus, bands, strangulated hernia, foreign 
body, intussusception, and appendicitis. If the vomiting persists, 
and the pain becomes of a gradually increasing intensity and 
spreads over a wider area, it is certain that the intestinal lesion is 
one of increasing gravity. At the same time, should a chill and 
rise of temperature accompany or precede these symptoms, it is 
very likely that the trouble is of an inflammatory nature. If the 


pain is paroxysmal, with no rise of temperature, colic should be 
thought of, or else an obstruction should be sought. Likewise, if 
the pain is of a griping character, and is accompanied by diar- 
rhea, enteritis is most probable. It is characteristic of patients 
whose pain is due to lesions of the lower bowel that they try to 
ease it by lying with the back bent and the lower limbs flexed. 
In case the pain is due to a spasm of the intestinal muscles, pres- 
sure and heat over the area affected will often give relief. If 
the lesion is inflammatory, heat and pressure increase the pain, 
while cold often produces ease and comfort. 

Manner of Onset. — Intestinal pain may be gradual or sudden 
in its onset. When the onset is gradual with a slow increase in 
the intensity, we know that the lesion is gradually increasing in 
severity. The most common lesions which have gradually in- 
creasing pain are those of an inflammatory origin, such as aj)pen- 
dicitis, enteritis, and those tuberculous lesions causing peritoneal 
irritation, especially if these are of rapid progress. Should the 
onset be sudden it generally indicates a rather severe and unusual 
derangement of the intestinal viscera, such as may occur from 
knots, kinks, and intussusception. Generally in these lesions, and 
especially in all lesions which produce obstruction, enlargement 
of the bowel proximal to the site of the obstruction occurs, so 
that palpation of the abdomen will disclose a tumor mass, tym- 
panitic on percussion. If in a case of acute intestinal pain, tumor 
is absent and palpation reveals an area of exquisite sensitiveness, 
gradually increasing in extent, it frequently is an indication of 
a perforation of the bowel. This is especially true in those who 
are suffering from intestinal tuberculosis or from typhoid fever. 
Should the pain be acute in onset, and be relieved by vomiting, it 
indicates an intestinal spasm. This spasm usually is caused by the 
collection of gas due to fermentation or putrefaction of indi- 
gestible food, and often is followed by a diarrhea which lasts 
for a day or two. Should acute pain occur, followed by vom- 
iting which finally becomes stercoraceous, it indicates an ob- 
struction which, unless relieved, is sure to cause the patient's 


In tliose obstructive lesions in which a tumor formation is 
present auscultation reveals exaggerated peristalsis over the tumor 
mass, with absent peristalsis below it in the area where the intes- 
tines are coUajDsed. In these conditions pain is also very com- 
mon after eating, coming on from one to seven hours after the 
ingestion of food. Should it come on immediately after eating, 
it is due to the stimulation of intestinal peristalsis by the en- 
trance of food into the stomach. 

Relation of the Position of the Patient to the Pain. — If the 
pain varies in intensity, depending wpon the position of the 
patient, inflammatory lesions, either acute or chronic, should be 
sought. Change of position sometimes causes the most pain, espe- 
cially after adhesions have formed. The pain is greatest in that 
position in which the abdominal parietes are dragged upon by the 
adherent bowel, and is always localized to the site of the lesion. 
Colics are generally indicated by great restlessness and activity of 
the patient, who often clasps his hands over the abdomen and 
exerts pressure upon it; on the contrary, inflammatory lesions are 
generally indicated by the patient assuming a j)osition in which 
the intraabdominal pressure is lessened. To do this, he lies flat on 
his back with his knees drawn up. In a case of inguinal or fem- 
oral hernia the lower limbs are flexed and at the same time rotated 

Relation of the Ingestion of Food to the Pain. — There are 
three periods in which after the ingestion of food intestinal pain 
occurs : 

(1) The first period follows immediately after eating, and 
lasts for a varying length of time. It is due to the excitation of 
intestinal peristalsis by the entrance of food into the stomach, 
and when present is a fairly good indication of an inflammatory 
lesion in the bowel. 

(2) The second comes on about one or two hours after eating, 
and persists for a couple of hours. It indicates a duodenal in- 
volvement, often an ulcer, or perhaps an inflammation. The 
two hours mark the duration of the gastric digestion, and time 
the beginning of the passage of the food from the stomach into the 


duodenum. Pain may also be present immediately after the inges- 
tion of food, but this pain only persists for a short time, and is then 
followed by the duodenal pain. The presence of adhesions around 
the duodenum, following common duct or gall-bladder disease, 
will also give rise to this type of pain. 

(3) When the pain is delayed, until four to seven hours or 
longer have elapsed after the ingestion of food, it is a sign that 
the trouble is low in the bowel. Appendiceal pain occurs from 
four to seven hours after eating, and is very prone to come on 
about midnight, provided the evening meal is taken around 
six or seven o'clock. If it occurs at a longer interval than seven 
hours it is an indication that the lesion is in the large intestine. 
This is especially true if rather indigestible foods, as stewed cab- 
bage, etc., have been eaten. 

Duration of Pain. —A pain of short duration, pathologically 
speaking, is generally of but slight moment, while one of long 
duration indicates a lesion of more or less severity. The more 
constant the pain, and the greater its intensity, the more should 
it merit our attention, not only because of the portent of harm to 
the patient, but also because of the necessity for the individual's 
ease and comfort to diagTiose and relieve the symptoms as soon as 
possible after examination has been made and charge of the case 
has been assumed. 

Result and History of the Pain. — A pain that passes off with- 
out any untoward result and is of a paroxysmal type generally is 
due to colic. If the pain is of this character, the different colios, 
such as hernial, foreign-body colics, volvular colics, and those due 
to enteritis, should then be quickly passed in mental review. Pan- 
creatic, biliary, urinary, and uterine colic also should not be for- 
gotten. If there be a history of recurring attacks, associated with 
vomiting and constipation, especially if a rise of temperature and 
pulse rate is present at the time of the attack, and tenderness on 
the right side is marked, appendicitis should be suspected. If the 
attacks are spasmodic, and successively shorter intervals occur 
between each successive attack, it is, in case of ulcerative lesion 
of the bowel, an indication that the stenosis, which is the cause of 


the attacks, is progressing, and that gradually the lumen of the 
bowel is becoming more constricted. 

Tenderness is of two types: (a) superficial, and (b) deep. 
The superficial tenderness often exists in the form of a hyper- 
algesia. This hyperalgesia is in well-defined zones, which have 
been described earlier in the chapter. Deep tenderness frequently 
is j)resent over the area of the bowel involved, and is due to local- 
ized peritoneal inflammation. When pain is felt at the site of 
the irritation it is called direct pain or tenderness. When it is 
felt in other areas it is called indirect pain or tenderness. 

In the diagnosis of intraabdominal lesions, especially those 
of the alimentary tract, tenderness may be of much importance. 
Where the tenderness is direct it is due to inflammatory irritation 
of the parietal peritoneum or of its subserous layer. An area in 
which direct pain is present is tender only when, on palpation, the 
pressure exerted is strong enough to irritate the peritoneal sub- 
serous layer. An area in which the pain is indirect (hyperal- 
gesia) is painful upon the slightest irritation. Even the drawing 
of the tip of the finger or of the head of a pin across the surface 
is extremely painful. This very marked superficial tenderness 
may or may not be found at the point where the deep mural 
tenderness, or tenderness on deep pressure would indicate the 
site of the lesion. 

Symptoms Associated with the Pain. — Symptoms associated 
with intestinal pain are: vomiting, diarrhea, tumor (tympanitic 
or dull on percussion), tympany, generalized or local, obstipation, 
shock and collapse, rise or fall of temperature, changes in pulse or 
respiration, diaphragmatic breathing, and ing-uinal glandular in- 

Vomiting is a symptom which, in obstructive disorders of the 
intestine, follows shortly after the initial pain. The longer it is 
in making its appearance the lower is the lesion in the bowel. In 
nearly all intestinal lesions the vomitus consists at first of the 
contents of the stomach, then, as the reversed peristalsis carries 
the food from the lower segments of the bowel, it becomes more 
and more fecal in character. From the time of the onset of the 


vomiting to that of the appearance of the fecal material (if the oh- 

struction is low in the bowel), a fairly good estimate of the location 
of the lesion can be made. 

Diarrhea, following in a few hours the onset of a pain, gener- 
ally indicates an enteritis, the pain being but an indication of the 
bowel spasm which is present. Should diarrhea follow at a consid- 
erable interval after the beginning of the attack, it is likely that 
obstruction of the bowel is present, and has progTessed to such an 
extent that peritonitis has been produced. It must be remem- 
bered, however, that diarrhea is not an invariable accompaniment 
of enteric obstruction, constipation being present in all cases in 
the early stages, and often persisting until the end. In localized 
bowel obstruction there is present a tympanitic tumor. If the 
tumor is in the center, and somewhat to the left of the median 
line, it indicates that the lesion is probably in the small bowel; 
while if it is in either flank, the large intestine is very apt to be 
at fault. A solid tumor associated with tympany may be due 
either to tuberculosis or to a new growth (benign or malignant) ; 
though, generally, neither of these causes any severe or marked 
pain, and their progress is gradual. 

Should shock and collapse be associated with severe abdominal 
pain, it may indicate the rupture of the intestine into the abdomi- 
nal cavity. The rupture may be due to previous ulcer formation, 
either typhoidal or tubercular. Typhoid perforation occurs most 
often during the third week of the disease, and is diagnosed by its 
characteristic signs ; while tubercular intestinal ulcers betoken 
their presence by special symptoms. Intussusception and volvulus 
are frequently associated at the time of their occurrence with con- 
siderable shock. The rujDture of an inflamed appendix causes 
great shock, and generally occurs only after the disease has been 
present for a few days. Temperature, pulse, and respiration are 
of value in the diagnosis of tuberculosis, typhoid fever, appendi- 
citis, and strangulated hernia. They are but slightly changed in 
volvulus and hernia. Pain on deep' inspiration, and the absence 
of diaphragmatic breathing are often valuable in the diagnosis of 
peritonitis originating from a perforated ulcer or a ruptured ap- 


pendix. Glandular enlargement is of but slight diagnostic impor- 
tance in clearing up the origin and cause of abdominal pains. 


Because of the manner of origin and peculiarities, intestinal 
neuralgia and colic merit a separate discussion. The lesions of 
the intestines will be considered in the following order: 

(1) Enteralgia. 

(2) !N'eurosis. 

(3) Inflammation. 

(4) Ulceration. 

(5) Adhesions. 

(6) Intestinal obstruction. 

(7) Diseases of special parts of the intestine, such as: (a) 
appendix; (&) colon; (c) rectum; {d) anus. 

Enteralgia. — That irritation which is interpreted as painful 
may of itself arise in the intestinal walls without an associated 
inflammatory state is very likely. Reasoning from analogy the 
terminal nerve filaments in the walls should be subject to irritation 
by toxic substances. This irritation sets up motor activities which 
are interpreted as painful. The stimulus (resultant of excessive 
motor activity) is carried by the sympathetic nerves to the cord, 
where collaterals of the spinal nerves are involved. This causes 
reflex hyperalgesia in the abdominal walls. Yet enteralgia, as a 
pathological entity, is very rare. Pains of other abdominal lesions 
are frequently mistaken for bowel pain, and the intestine is cred- 
ited with their production, when it has no association with them. 
Perhaps even more frequently organic lesions of the intestine are 
mistaken for enteralgia. How many times appendiceal, gall-duct, 
and pancreatic-duct colic are mistaken for it ! How often does the 
patient go on for years suffering from distressing symptoms asso- 
ciated with these disorders, when the cause could have been so 
easily removed, and the individual restored to comfort and hap- 
piness ! Schmidt, who quotes from Hawkins, evidently mistakes 


other lesions for enteralgia, for he says that "the pain of enter- 
algia is central, occurs in short, sharp attacks, quite as severe as 
a biliary or renal colic, and is equally attended with sweating and 
collapse." An analysis of the above should convince one that the 
pain which he describes as enteralgic may be nothing more than 
a colic of the intestine. In many cases the reason that 
the generic term enteralgia is applied to abdominal pain colicky 
m character is that a sufficiently painstaking observation has not 
been made, and a general and non-specific term has been applied 
to hide the confusion and diagnostic ignorance of the examiner. 
Enteralgia should be given as a cause of pain only after all other 
causes have been excluded ; and even then it may be possible that 
some undiscovered cause, such as local irritative lesions of the 
musculature, may be present. Besides the myalgic origin enter- 
algia may be caused by some such similar change as produces 
neuralgia in the cerebrospinal nerves, and we have, as it were, a 
neuralgia of the sympathetic. When a probable enteralgic pain is 
present, without any apparent lesion, the patient's general condi- 
tion should be carefully studied, to find out if any of the disturb- 
ances which are known to produce neuralgia are present. If they 
are found a tentative diagnosis of intestinal neuralgia may be made 
until something more definite is discovered. 

Pain Due to Functional Disturbances. — The functional dis- 
turbances of the intestine producing pain are either secretory or 

Secketoey Distttebances. — That it is possible for secretory 
derangement of the intestine to cause pain cannot be disputed. 
The disturbance that causes the most pain is a hyper- not a hypo- 
secretion. It must be conceded, however, that an oversecretion of 
intestinal juices cannot of itself cause pain, unless there is asso- 
ciated with it some local lesion causing either an inflammation or 
a circumscribed spasm. When the bowel is stimulated on its 
internal surface by a local irritant it reacts by a hypersecretion of 
mucus. This mucus, in its passage down the bowel, becomes 
rolled into balls, or else adheres to the intestinal wall, so that a 
greater than normal contraction of the musculature of the intes- 


tine is necessary to force it on. Thus spasm, with its resulting 
pain, is produced. It is not known whether a change in the chemi- 
cal composition of the intestinal secretion can so occur that the 
secretion may of itself become irritating. 

Motor Disturbances — Enteeospasm. — Motor disorders, 
such as spasm of the intestine, are a potent cause of pain. The 
spasms are due to some local irritative lesion in the bowels or 
are the result of referred stimuli. The local cause produces a 
contraction, restricted, as a general rule, to a small area of the 
bowel; while the contraction spasm, due to a central stimulation, 
may extend over a considerable section of the bowel. These re- 
ferred stimuli may result from some disorder of the sympathetic 
nerves or of their ganglia, or may possibly be due to a lesion in the 
cerebrospinal system. Such causative factors are found in neu- 
rasthenia, either of the sympathetic or of the cerebrospinal type. 

The local lesions causing intestinal spasm are most frequently 
the result of irritation from undigested food, irritative poisons, 
and foreign bodies. The spasm resulting from this irritation 
gradually progresses downward, following in its course the descent 
of the irritating substance. Likewise the pain gradually moves 
from the epigastrium down over the anterior abdominal wall, until 
it becomes localized in the suprapubic region. In other cases 
the irritation may be localized and non-progressive, and the pain 
is stationary. When such a condition is present inflammation or 
ulceration is most commonly the cause. 

The pain of enterospasm is divided into two classes : (a-) pri- 
mary and (h) secondary. 

(A) The primary pain is due to two causes: (1) the pres- 
sure made by the contracting muscular walls upon the nerves ter- 
minating between the muscle bundles. Lennander's experiment 
on the intestine with electrical stimuli, which caused contraction 
and no pain, is non-conclusive, as the adequate stimulus was ab- 
sent, and the contraction one of an entirely different kind than 
that which normally is present in the intestines. 

(2) The pull and drag exerted upon the mesentery by irreg- 
ularities in the size of the bowel. 


(B) Secondary pain is due to distention of the bowel proxi- 
mal to the area of spasm. It is of the ordinary, colicky type, its 
duration depending upon the kind and manner of the irritation. 
Should the irritation be of a transient nature, as is found in dis- 
turbances due to the passage of indigestible food, the pain is in- 
termittent and varies in location, though it constantly progresses 
toward the lower part of the abdomen. Should the lesion be or- 
ganic the pain ic permanently localized and is not progressive, but 
remains at the point related to the bowel proximal to the point at 
which the intestinal distention begins. The colon, owing to its 
being most exposed to irritation, is most frequently the part of 
the bowel involved in the spasm. In mucous colitis the attack is 
typical (see Colon). 

In a case reported by Hawkins and quoted by Maylard ^ a good 
description of colon spasm is given: "In this patient attacks 
came on once in about three or four years. They began as a con- 
stipation, which was difficult to relieve ; distention ensued, and 
with it pain and vomiting. The pain was aggravated by the 
taking of food and by defecation. At the operation, which was 
performed for the relief of this condition, two areas of contrac- 
tion spasm, without any associated lesions, were found. The first 
was at the junction of the descending colon and the sigmoid flex- 
ure. The second was in the small intestine. Both areas showed 
a spasm of the musculature of such magnitude that nothing could 
be passed through the lumen of the bowel. In both the narrowed 
part of the bowel passed abruptly into the normal parts above 
and below." 

That such a localized spasm occurs is known to every practi- 
tioner of medicine. Many and many a patient complains of fleet- 
ing, colicky, abdominal pain, persisting off and on for years. 
Operation, should it be undertaken, reveals conditions somewhat 
like those described above, or shows nothing, in which case the 
appendix is often blamed, and sometimes rightly, for many cases 
of colic owe their origin to a fibroid- appendix. This, because of 
its constant irritation, produces abnormal excitability to stimuli 

^ Herbert P. Hawkins, British Medical Journal, January 13, 1906, p. 65. 


in the sympathetic nerves and plexuses which supply it. This 
excitability, in^turn, is communicated to adjacent centers supply- 
ing the small intestine, which may also become involved and be 
thrown into a state of pathological excitability. When they are 
in this condition, stimuli that ordinarily would produce no reac- 
tion may cause pain, or else may reflexly produce spasms of the 
bowel, which in turn cause pain. 

In some cases, because of generalized abdominal symptoms, 
enterospasm has been diagnosed as peritonitis. The following, 
which are present in enterospasm and absent in peritonitis, aid in 
the diagnosis: (1) The low temperature, pulse, and respiratory 
rate; (2) the excess of peristalsis, even though the abdomen may 
be rigid and tender; and (3) the absence of any tendency of the 
process to increase in severity. 

The intestine, because it has a lumen of a fairly constant size, 
is subject to spasm-pain throughout its entire length. Because of 
the progressive nature of the spasm, the pain is felt at different 
points on the abdominal wall, depending upon the part of the 
intestine which is involved. 

In some cases spasmodic musculature contraction of the small 
bowel occurs without any apparent organic cause, and is due to 
abnormal functional activity. Those who are subject to these 
spasms are so sensitive to irritative nervous influences of any kind 
that the slightest change from the normal may cause a spasmodic 
contraction of the bowel. This change also may be the result of 
local changes (slight fermentation) in the intestine (producing a 
local colic), or may be due to causes acting from a distance, such as 
exposure to cold drafts, which produce an internal congestion, 
etc. During bodily fatigue colic is also felt. The bowel contrac- 
tion in the latter case is probably due to the irritation from the 
toxic materials circulating in the blood. Excessive heat may abo 
act in the same manner. 

All these disorders cause a derangement of intestinal secre- 
tion, with consequent fermentation and putrefaction of the intes- 
tinal contents. These, in turn, irritate the intestinal mucosa, and 
this irritation may, in some cases, progress to an active inflamma- 


tion of the bowel. In any case diarrhea is a frequent accompani- 
ment of this condition. It indicates that the changes in the mucosa 
and bowel contents act as irritants and cause an excessive contrac- 
tion and forcible propulsion forward of the bowel contents. How- 
ever, the only structure particularly affected is the mucosa, which 
at the time is in a state of weakened resistance. This reduction in 
resistance is often caused by congestion incidental to the chilling 
of the body surface, in which a peripheral vasomotor contraction 
occurs. A similar vasomotor spasm may also be caused by emo- 

f Descending colon, 
\ sigmoid 

I Appendix, cecum, 
\ ascending colon 

Transverse colon 

Fig. 102. — Pain Areas in Colonic Colic. 
Colonic colic begins around the umbilicus and radiates in the directions 
indicated. The pain of all colics of the colon is generally referred at first 
around the umbilicus and then later to the area below it. However, if the 
lesion is in the small bowel the pain is referred above this level. 

tional stress, such as is present in anger and extreme joy or 

Colics may be the result of some definite error in diet, such 
as 'the eating of indigestible or bad foods. Many persons cannot 
indulge in whiskey, eat highly spiced foods, nor drink very cold 
or unsuitable liquids without suffering from colic. People vary 
somewhat in susceptibility, so that what one person can do or 
take with immunity will in another cause colic. 

Since these attacks of colic often follow a slight indiscretion 


in diet, possibly such an indiscretion as has occurred many times 
previously without the production of colic, the patient is apt to 
ask, and the physician himself should know, the reason of its 
greater frequency at one time than at another. Its incidence is 
probably determined by a lessened resistance due to changes in 
atmospheric conditions, or to removal from one locality to an- 
other, especially among those who are not accustomed to traveling. 
In these the colic is probably due to change in habits and diet. 
Constipation, with irregular evacuation and overfeeding, is an- 
other cause of this colic. 

The most reasonable hypotheses as to the cause of colic are 
those promulgated by IS^othnagel, Lennander, and Wilms. Noth- 
nagel says that colic is due to tetanic contraction of intestinal 
muscles and the anemia produced by this contraction. Lennander 
claims that in colic in the small intestine the pain is due to 
pressure against the sensitized parietal peritoneum by the tetanicly 
contracted loop of small intestine, and that pain from similar peri- 
staltic action of the large intestine is due to traction on its short 
mesentery. On the other hand, Wilms believes that colic in both 
the large and small intestines is due to traction on the mesentery. 
The simple explanation is that the pain of colic is that caused by 
distention of the muscular walls. It is a special type of pain 
conveyed by the sympathetic. 

Colics generally are sudden in onset. The pain commences 
around the umbilicus, and thence radiates either above (small in- 
testine) or below (large intestine). The advance of the intestinal 
spasm is often indicated by changes in the location of the pain. 
When the spasm is in the small intestine, the pain is above the 
umbilicus; when in the jejunum, cecum, and appendiceal region, 
the pain is around the umbilicus; when the large bowel is in- 
volved, the pain is below the umbilicus, and, as the spasm pro- 
gresses toward the rectum and anus, the pain passes down toward 
the pubes, and becomes lower and lower, until it rests just above 
the pubes, which is a sign that the bowel contents have reached the 
sigmoid. The pain now remains stationary until the fecal mass is 


At the time when the colic is at its greatest intensity the pain 
"may be so severe as to cause the patient to cry aloud. He also 
is very restless, moves constantly about, throws his limbs in all 
directions, and often lies prone upon the bed or upon the floor. 
Frequently he presses a pillow or his hands tightly over the 
abdomen. This seems to relieve the pain (see drawing). 

Type of Pain in Colic- — The pain may be either intermittent 
or constant. When intermittent, it becomes lower and lower 
in the abdomen, and finally ceases on the expulsion of flatus or 
feces. Should the pain be constant, it shows that the obstruction 
has become constant and persists at one place. An obstruction of 
this kind is present in strangulated hernia and intussusception. 
Intermittency in a colicky pain shows that the obstruction has 
only been temporary. Such an obstruction may be produced by 
kinks in the bowel, hardened fecal masses, and the like. Relief 
of the pain indicates that the obstruction has been overcome. An 
onward movement of the bowel contents follows, and frequently 
gives rise to a gurgling. If the obstruction becomes permanent a 
considerable local distention takes place and causes tumor forma- 
tion, excessive proximal peristalsis, and an absence of gurgling 
over the tumor. If pain persists and is accompanied by diarrhea, 
vomiting, and abdominal tenderness, it is a good indication that 
inflammatory changes have taken place. 

Tenderness is associated with enterospasm. The amount of 
the tenderness depends on the location and the extent of the 
bowel involvement. It seems to be the rule that disturbances at 
either extremity of the small or large intestine give rise to a 
gi-eater degree of tenderness than do those of the middle part. 
The tenderness may be indirect, as illustrated in involvement of 
the transverse colon, where pressure on the abdomen above the um- 
bilicus in the region of the colon will cause pain which is not felt 
in the area over which the pressure is made, but in the anterior 
abdominal wall below the umbilicus. If the small intestine is in- 
volved, pressure on the abdominal wall, particularly kneading of 
the abdominal contents, will produce pain in the epigastrium. 
Local tenderness over the site of a bowel lesion is unusual, unless 


the abdominal wall (parietal peritoneum and subserous layer) is 
also involved. 

Intestinal colic should be diagnosed from gall-stone, renal, 
and uterine colic, pyloric spasm, perforation of the bowel, appen- 
dicitis, acute pancreatitis, mesenteric embolus, and thrombosis; 
from the referred pains due to thoracic diseases, as pleurisy, pneu- 
monia; and also from the abdominal crises occurring in certain 
diseases of the nervous system, as tabes, etc. 

Should colic be present without any well-defined bowel lesion, 
particularly if it occurs in a painter or in one who is accustomed 
to handle considerable quantities of white lead, it is well to find 
out if the cramp is due to plumhism, pathognomonic signs of 
which are stippling in the red blood cells, the blue line on the 
gums, and the wrist drop and foot drop (only occasionally, in the 
early cases), or other signs of neuritis. Contraction and rigidity 
of the abdominal muscles occur at the same time as the colic. In- 
equality of the pupils and tenderness over the nape of the neck 
are also to be noted. 

The colicky pain, as a rule, is felt in the center of the abdo- 
men, in the umbilical region. The sensation is that of the intes- 
tine being twisted. Some describe it as a feeling in which it seems 
as though the bowels were being tied in a knot. During the colic 
the arterial tension is raised and the pulse is hard. Pal says that 
the pain of lead colic is due to irritation and constriction of the 
blood vessels in the intestinal walls, and that this indirectly irri- 
tates the sympathetic nerve filaments. 

There is also a colic associated with uremia. In this condi- 
tion, beyond the colic, the only other symptoms are those of 
the uremia. 

Inflammation of the Bowel. — Inflammation of the bowel, as 
a rule, causes little pain as long as there is no excess of motor 
activity. When active peristalsis occurs there is a well-defined 
pain ; and if the parietal peritoneum is invaded a local tenderness 
is added which, as a rule, is confined to the involved area of the 
abdomen. When all the coats of the bowel are involved in the 
inflammatory process, pain is also reflected to the anterior abdomi- 






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nal wall, and hyperalgesia is present in the cord zones associated 
with the intestine. 

In inflammatory states of the small intestine entrance of food 
into the stomach may, by stimulating and increasing the peri- 
stalsis, aggTavate a pain already present, or initiate one, if none 
is present. This inter-relationshij) of the stomach and intestine 
can be explained npon the hypothesis of the close nervous connec- 
tion between the two organs, so that a stimulation of gastric peri- 
stalsis will likewise cause an increase of intestinal movements. 

A confirmatory symptom of value in the diagnosis of inflam^ 
mation of the bowel is diarrhea, which in acute enteritis or colitis 
is due to irritation by indigestible or fermenting substances. It 
is of a foul odor and contains frothy material. In tuberculous 
enteritis the stool is also foul, and contains blood and shreds of 
tissue. The diarrheal stool of an inflammatory intestinal lesion 
(enteritis) is generally acrid, and produces intense irritation 
around the anus and buttocks, while other diarrheal stools, as a 
rule, do not excoriate. 

Since many of the inflammatory processes are accompanied by 
fermentative changes in the intestinal canal, it follows that a 
considerable distention of the bowel from gas frequently is a con- 
comitant symptom. When it occurs, the pain of the distention is 
engrafted on to that of the inflammatory process. 

In some cases of inflammation of the bowels the inflammatory 
process is very severe and extends to adjacent structures. In this 
event, because of the involvement of the peritoneum, the sub- 
jective pain is associated wdth considerable local tenderness, and 
if the cecum or lower end of the ileum should be involved it may 
be confused with appendicitis. This is all the more likely to 
happen when the abdominal muscles over these areas are in a 
state of rigidity, and vomiting and rise of temperature are present. 
If the inflammation should be in the duodenum the abdominal 
pain is constant, and there is an increased sensitiveness to pres- 
sure in the right hypochondriac region. Duodenitis generally oc- 
curs in a patient suffering from an acute gastritis, and in the 
stools mucus, with or without blood, will be found. Duodenal 


digestion, according to O'Connell, occurs about tliree o'clock in 
the afternoon and two in the morning; therefore, at these times 
the pain would be most severe. 

Ulcers of the Intestine. — The pain in ulcers of the intestine is 
felt most often in the region of the umbilicus, though the exact 
localization of the pain depends largely upon whether the lesion 
is in the small or in the large intestine. In intestinal ulceration 
the pain is more restricted than in inflammation, and the area or 
point of tenderness does not move about, as it does both in the 
latter condition and in colics which are the result of eating indi- 
gestible food. The pain of ulcer is frequently accompanied by 
diarrhea, and occult blood can, in some instances, be demonstrated 
in the stools. A factor of importance in the diagnosis of the loca- 
tion of the ulcer is in the relationship of the attack of pain to the 
time of the ingestion of food. Should the pain come on a few 
hours after eating, the duodenum is most likely to be involved; 
while if the interval is longer the lesion is apt to be lower in the 
bowel. When an interval of seven or more hours elapses before 
the commencement of the pain, the lesion is probably in the large 
intestine. Another point of importance in diagnosing the loca- 
tion of an ulcer is that the lower it is in the bowel the less is the 
likelihood of diarrhea. If the pain becomes constant, and is asso- 
ciated with a steadily increasing distention of the intestine, 
stenosis of the bowel following an ulcer can be diagnosed. 

In intestinal ulceration there are, at first, intervals of freedom 
from pain ; but as the bowel lumen becomes narrowed from stric- 
ture formation, the intervals of freedom become less and less, un- 
til finally the pain is almost constant. This pain is relieved by 
the passage of the gas present in the occluded bowel. Some- 
times rubbing and massage, although they may temporarily in- 
crease the pain by the extra intra-intestinal pressure which they 
produce, will finally cause a passage of the gas and consequent 
relief. , Vomiting also appears, and, as the lumen continues to 
narrow, gradually becomes worse, until complete obstruction oc- 
curs. It is violent, persistent, and stercoraceous. 

In ulcer of the intestine, food, particularly that which is hard 


to digest, maj act as a local irritant and increase the contraction 
of the bowel, with a consequent drag and pull upon the ulcerated 
area, and thus cause pain. Unripe fruit or vegetables, such as 
corn and cabbage, are very likely to act as irritating factors. 

It is claimed by Schmidt that the application of cold com- 
presses to the abdomen will relieve the pain of intestinal ulcer, 
while application of heat will increase it. 

The pain of ulcers of the intestine generally is not very 
severe, except when they occur in the duodenum, the sigmoid, or 
the rectum. Large areas of ulceration in any portion of the bowel 
are very painful, especially if the ulceration be deep enough to 
involve the peritoneum. In these cases the areas of local tender- 
ness over the abdomen are proportionate in size to the area of the 
peritoneum which is involved. In ulceration of the rectum tenes- 
mus is frequent. The different varieties of intestinal ulceration 
are tuberculous, typhoidal, syphilitic, catarrhal, uremic, trophic 
ulcers and those following burns. 

TuBERCiJLGUs Ulcees.- — I^ou-progressive tuberculous ulcera- 
tion of the intestine is often painless. Should the ulceration pro- 
gi'ess pain is present. It may be caused by an associated enteri- 
tis, intestinal distention following a stenosis, a fermentation, or 
peritoneal involvement. Tuberculous ulcers of the duodenum, be- 
cause of the frequent location of the pain in the epigastrium, 
are often confused with pyloric spasm or gastric ulcer. A diag- 
nostic point of value between the two is that in pyloric spasm the 
vomitus never contains bile, while in lesions of the small or large 
intestine usually it is at least tinged with bile. Diarrhea of a very 
offensive odor is frequent in tuberculous ulceration. Tubercle 
bacilli may, in some cases, be found in the stools. Reaction to 
tuberculin, signs of emaciation, night sweats, and probably some 
lung involvement can also be detected. 

Typhoidal IlLCEEATioisr. — Typhoidal ulceration is generally 
painless, though in tyj)hoid fever it is common for the patient to 
complain of discomfort in the lower abdomen, and in some cases 
of tenderness in the right iliac fossa. If the onset of the fever is 
sudden, there may be generalized body pain and headache. If 


the development is slow and gradual, and no acute toxic condition 
is present, the only pain-phenomena may be a zone of tenderness 
over the tenth or eleventh dorsal visceral segments. 

Syphilitic Ulceration. — Syphilitic ulcers of the bowel, as 
a rule, are painless. Should constant pain in the abdomen occur 
in a syphilitic, and be accompanied by diarrhea, and, in some 
cases, by vomiting, a diagnosis of syphilitic intestinal ulcer would 
be tenable. 

Cataekhal Ulceration causes no pain, unless the ulceration 
is very deep. The same is true of the ulceration the result of 
uremic and trophic changes. 

Ulcers Following Burns. — Ulcers following burns are 
common. They are most frequent in those cases in which the 
burn is on the abdomen. When they occur they are most likely to 
be in the duodenum (see Duodenal Ulcer), and give rise to no 
special symptoms, other than those which occur in simple intes- 
tinal ulceration. The pain produced by them is apt to be over- 
looked by the patient, because of the much greater pain which is 
the direct result of the burn. 

Duodenal Ulcers. — The pain of duodenal ulcer, like that of 
gastric ulcer, is paroxysmal. It may be of intense severity, or 
may be felt merely as a dull discomfort coming at certain inter- 
vals following the ingestion of food. In other cases, whether 
severe or dull, it is more lasting, and sometimes a constant sense 
of burning or of sharp pain is experienced. This in many cases 
is relieved by the ingestion of food, therefore it received the name 
'^hunger-pain." The pain is situated to the right of the middle 
line, and usually a little above the level of the umbilicus. It 
may radiate toward the right or the left side. Sometimes it is 
described as having a deep-seated location, being rather unlike 
the characteristic pain of gastric ulcer in this particular. The 
time of its appearance varies. It may follow immediately after 
the taking of food, but most often does not appear or, if it does 
appear, does not reach its maximum -of intensity until two, three, 
or four hours after eating. The character of the ingested food 
has a certain relationship to the intensity and occurrence of the 


pain. Generally speaking, heavy meals occasion a pain of greater 
severity, although the pain is later in appearance than after light 
meals. The drinlcing of copious draughts of water, or the taking 
of other liquids, such as milk, beer, and wine, or the ingestion of 
alkalies, may relieve the paroxysm for a time. 

Tenderness and rigidity of the abdominal muscles in the right 
upper segment of the abdomen may be met with. Pressure 
usually increases the i^ainful paroxysms, although not invariably. 
That the site of the ulcer bears a relationshij^ to the site of the 
pain cannot be doubted, though the idea that the pain, localized 
tenderness, and muscular rigidity occur directly over the site of the 
ulcer is not tenable. 

The pain in duodenal ulcer may be situated in the epigastrium, 
near the mid-line, and may extend to the right so that it lies be- 
tween the crest of the ileum and the ribs. In this condition there 
is also often a tender spot to the right of the lower dorsal vertebra. 
It is claimed by many (Deaver, among others) that the pain in 
duodenal ulcer shows a tendency to periodicity, so that it may be 
absent for long intervals and then occur in an attack of varying 
intensity. Tlie pain of duodenal ulcer is increased by moving, 
eating, or pressure. In many cases there is also present in the 
abdomen a feeling of gnawing or of boring. 

Many theories have been advanced to accotmt for the pain in 
duodenal ulcer. Three suppositions underlie all these theories, 
namely: (1) That the HCl, because of its reflex excess of secre- 
tion, directly irritates the ulcer and thus causes the pain. But, if 
this is so, there must be many exceptions, for a duodenal ulcer, 
without an excess of HCl in the stomach, is frequently found. In 
fact, it seems that the ulcer is the cause of this increase of secre- 
tion, and that the only elfect of the excess is that by irritating the 
surface of the ulcer, it causes a reflex contraction of the pylorus. 
This leads us to the second supposition, so actively championed 
by Hertz, (2) that the pain is nothing more than a tension pain, 
due to localized distention of the stomach walls, the result of 
excessive stimulation from the HCl. It is known that the pylorus 
remains closed while the duodenal contents are acid, and that it 


relaxes only when the contents become alkaline. In duodenal 
ulcer the duodenal contents are, because of the excessive secretion 
of HCl in the stomach, seldom, if ever, alkaline. Consequently 
the stomach is always in a state of hypertension, the result of 
abnormal peristalsis. This hypertension, however, exists only on 
the prepyloric portion of the stomach, because it is into this por- 
tion that the food is forced by the peristalsis and, being unable to 
advance because of the closed pylorus, accumulates and causes the 
increase of tension and the so-called ulcer pain, which has about 
the same location as that described under pyloric spas